LIBRARY OF CONGRESS. 



®[fHp. . Sopnwgtffi f 0,3.4.0 

Shell :?- 



UNITED STATES OF AMERICA. 



MENTAL DISEASES 



LECTURES 



MENTAL DISEASES 



DESIGNED ESPECIALLY FOR 



MEDICAL STUDENTS AND GENERAL 
PRACTITIONERS. 



T- " 



HENRY PUTNAM STEARNS, A.M., M.D., 

PHYSICIAN SUPERINTENDENT OF THE HARTFORD RETREAT, LECTURER ON MENTAL DISEASES 
IN YALE UNIVERSITY, MEMBER OF THE AMERICAN MEDICO-PSYCHOLOGICAL ASSOCI- 
ATION, MEMEER OF THE NEW ENGLAND PSYCHOLOGICAL SOCIETY, HONORARY 
MEMBER OF THE BRITISH PSYCHOLOGICAL ASSOCIATION, HONORARY 
MEMBER OF THE BOSTON MEDICO-PSYCHOLOGICAL SOCIETY, MEM- 
BER OF THE AMERICAN MEDICAL ASSOCIATION, ETC., ETC. 



WITH ILLUSTRATIONS. 



PHILADELPHIA : H 9 ty I 7 X 

P. BLAKISTON, SON & CO., 

IOI2 WALNUT STREET. 

1893. 






Copyright, 1892, by P. Blakiston, Son & Co. 



Press of Wni. F. Fell & Co. 

1220-24 Sansom St. 

philadelphia. 



TO THE PHYSICIANS 

WHO, 

AS STUDENTS IN MENTAL DISEASES, 

HAVE BEEN 

UNDER MY INSTRUCTION IN YALE UNIVERSITY, 
THESE LECTURES 

ARE 

RESPECTFULLY DEDICATED. 



PREFACE 



The following lectures have been prepared as a basis for 
instruction in Mental Diseases to the medical students of 
Yale University. They are now published, in the hope 
that they may be of service not only to students in other 
Medical colleges and schools, but also to general prac- 
titioners. 

The principal works consulted in their preparation are 
those of Ball, Dagonet, Voisin, Griesinger, Obersteiner, 
Lewis, Maudsley, Spitzka, and the excellent manual of Tuke 
and Bucknill. I gladly embrace the present opportunity to 
express my many obligations to the authors of these works. 

I am indebted to my friend, Dr. Henry M. Hurd, for 
valuable suggestions, and to Dr. W. L. Worcester for 
assistance in proof-reading. 

I have used illustrations for the first few pages of the 
introductory lecture, three of which are from Blackburn's 
" Manual of Autopsies," and twelve from Obersteiner's 
work on " Central Nervous Organs." 

An Appendix, comprising the most important parts of 
the laws of the several States and Territories, relating to 
the duties and responsibilities of physicians concerning the 
insane at the present time, will be found convenient for 
reference. 

Hartford Retreat, Hartford, Conn., 
December ij, i8g2. 

vii 



CONTENTS 



LECTURE I.— THE PHYSICAL BASIS OF THOUGHT. 
Advance in the Study of the Minute Anatomy of the Brain — Lobes, Convolu- 
tions and Fissures of the Brain — The cortex cerebri — Grey matter of the 
Brain — Central Ganglia — Optic Thalami — The Striate Bodies — Two Kinds 
of Nerves, the Sensory and Motor — Anatomy of the Nerves — Anatomical 
Arrangements of the End Organs of Sense — Functions of the Nerves — ■ 
The Transmission of Irritations to and from the Cortex — Functions of 
Nerve-cells and Nerves Contrasted — Transformation of Irritations into 
Sensations — The Thought-process in its Relation .to the Molecular 
Activities of the Nerves and Cells of the Cortex— The Evolution of Sensa- 
tions, Perceptions, Thoughts, Purposes, and Opinions — The Mind, Per 
sonality, Ego — Views of Different Authors — Nerve-energy — Agents which 
Affect it — Measurement of its Degree of Action — Derangement of its 
Normal Action the Initial Element of Insanity, pp. 9-47 

LECTURE II.— HALLUCINATIONS— ILLUSIONS. 

Definition — /Etiology — Difference in Hallucinations of the sane and insane — 
Modifications in the Circulation — Congestions — Toxic Agents— Inflamma- 
tions — Imperfect Nutrition — Hallucinations of Hearing — Illustrations — 
Hallucinations of Sight — Frequency of — Hallucinations of Smell — Hallu- 
cinations of Taste — General Sensation — The Sexual Organs — Import of 
Hallucinations — May Lead to Homicide or Suicide — Often present in 
Larvated Epilepsy — Intensity of Hallucinations — Frequency of — Table of 
Cases — Treatment. 

Illusions — Definition — Illusions of Sight — Illusions of Visceral Sensibility — 
Very numerous — May depend upon the existence of morbid growths — 
Present in Delusional Insanity — General Paresis and Melancholia. 

pp. 48-65 

LECTURE III.— IMPERATIVE CONCEPTS INSISTENT 

IDEAS. 
Concepts — Definition of — ./Etiology — Mode of Origin — Forms of Disease — 
Progress and Course — Illustrations — Character of Concepts — Signifi- 

ix 



Xll CONTENTS. 

in Power of Attention — The Result of Imperfect Functionating of the 
Thought Process — Fixed Delusions are Rarely Present in Acute Mania — 
Transient Delusions May be Present — Course and Progress of Acute 
Mania — Exacerbations — May Assume a Remittent Type — The Symptoms 
of Other Forms of Disease May Become Modified During an Attack of 
Mania — Counter-Irritation — Terminations — First in Recovery — Danger of 
Relapses — May Pass into a Chronic State — Symptoms of Such a Condi- 
tion—Dementia — Excitement — Delusions — Table of Cases of Acute and 
Chronic Mania — Prognosis — Treatment — Importance of Sleep and Con- 
servation of Physical Strength — Importance of Asylum Treatment — Hy- 
drobromate of Hyoscine — Bromide of Ammonium — Chloral — Paralde- 
hyde — Hot Baths — The Wet Pack — Out-of-door Exercise— Cannabis In- 
dica — Quiet — Nourishment — Importance of Early Feeding, pp. 183-201. 

LECTURE X.— PRIMARY DELUSIONAL INSANITY. 
Mode of Development — Contrasted with those of Melancholia and Mania — 
Patients not much Excited or Depressed by the Presence of Delusions — 
Chief Symptoms of the Disorder — Delusions Arise de novo, and are not 
the Result of any Antecedent Mental Disease — ^Etiology — A Neurosis 
Inherited or Developed — Imperfect Development of the Bones of the 
Skull — Meningitis, Injuries, etc. — It more often Appears during the 
Epochs of Life — Symptoms — In the Prodromatous Stage — Tendency to 
Solitude — Distrust — Eccentricities— Irritability and Brooding — Tendency 
to Reverie and Subjectivity — The Primary Stage may Cover Months or 
Years — The Essential Element of fully Developed cases is Delusions 
— Hallucinations of General Sensation — Often Present in the Back, Sides, 
and Genital Organs — The Character of Delusions may Partake of Exal- 
tation or of Pseudo-Depression — Memory — Illustrative Case — Letters of 
the Patient — Personality Overwhelmed by the Strange Concepts and 
Dominant Ideas, etc., pp. 202-219 

LECTURE XL— PRIMARY DELUSIONAL INSANITY. (Con- 
cluded.) 

The Cause of Delusions may be a Super-sensitiveness of the Spinal Cord — 
Tension of the Mental State — Letter — Mind-reading — Letter — Case — No 
Transformation after Seven Years — Intensity of Hallucinations in Some 
Cases — Hallucinations of Smell Most Frequent in Cases having a Sexual 
Origin — Case 2 — Letter — Case 3, Illustrative of its Slow Development 
— A Large Degree of Mental Activity Exists for Many Years — The 
Character of the Hallucinations may Indicate a Sexual Origin — Letter 



CONTENTS. Xlll 

— In Many Cases a Transformation from a State of Depression to one 
of Confidence and Partial Excitement Occurs — Persons Become the 
Owners of Vast Estates — Kings, Queens, Illustrative Cases — Peculiar 
Writing, with Translation — Cases in which the Delusions have been from 
the First of an Exalted Nature — Case — Prognosis — Recovery Sometimes 
Occurs in Acute Cases — Remissions of Considerable Duration — Treatment. 

pp. 220-241 



LECTURE XII.— FOLIE CIRCULAIRE. 
Cases of Folie Circulaire Not Numerous — Impossibility of Deciding Before- 
hand whether a Case of Mania will Eventuate in Folie Circulaire — Two 
Stages of the Disease — .Etiology — Heredity — Climatic Influences — 
More Frequent in France than in England — Symptoms — Those of 
Mania — Mental and Physical Faculties Become Excited — Period during 
which the Patient is Relieved — He Passes into the Stage of Depression — 
During the Excited Period Confusion of Ideas Rarely Exists — The 
Memory Good — A Moral Defect Present — Dress and General Ap- 
pearance — Craving for Stimulants — Painful Emotions — Forebodings — 
Desire to Remain Indoors and Frequently in Bed — The Length of a 
Full Period of Excitement and Depression — Case — Patients May at 
Times Exhibit Very Little Mental Impairment — Importance of Recog- 
nizing the Character of the Disease — Case — Prognosis — Recoveries. 

pp. 242-256 



LECTURE XIII.— DEMENTIA. 
Dementia and Idiocy — Distinction — Definition of Dementia — Importance of 
Averting an Issue of Dementia in Cases of Mania — It Rarely Occurs as a 
Sequel of Delusional Insanity — Symptoms — The Degree of Dementia 
Varies Very Much in Different Cases — Prevalence Among Chronic Cases — 
Periods of Excitement — The Transition to a State of Dementia is Generally 
Gradual — Third Class of Dements — Symptoms — Delusions — Sequential to 
Attacks of Mania and Melancholia — Three Forms of Dementia — Ten- 
dency to Merge into Each Other — Lines of Clinical Distinction Cannot 
be Definitely Drawn — Cases 1 and 2 — Prognosis in Primary Dementia — 
In Secondary Delusional Insanity — Treatment — Importance of State Pro- 
vision for Proper Care — Two Methods — Boarding Out of Such Patients 
Among Farmers — Public Institutions — Advantages of the Latter Method. 

pp. 257-272 



XIV CONTENTS. 

LECTURE XIV.— ADOLESCENT INSANITY. 
Two Epochs of Life — Adolescence and Senility — ^Etiology — Heredity — Char- 
acteristics of Pubescence and Adolescence — Motor Activity — Evolution 
of Sexual Functions — Development of Brain Capacity — Reasons Why 
there Occur so Few Cases of Insanity at these Periods of Life — Causes 
Ordinarily Potent Not Operative — Physiological Reasons — Heredity 
Comes into Forceful Activity Later in Life in Most Forms of Disease — 
Symptoms — Exaltation or Depression, Both in a Modified Form — Little 
of Maniacal Excitement or of Mental Pain — Both of Short Duration, 
and Succeeded by a State of Hebetude or Apathy — Case Illustrating Ten- 
dency to Recurrence, pp. 273-285 

LECTURE XV.— ADOLESCENT INSANITY. (Concluded.) 
Case 2 — As Age Advances the Tendency to a More Protracted Period of 
Excitement Increases — The Catamenia — Cases 3 and 4 — Absence of 
Acute, Prolonged Excitement or Great Depression, also of Fixed De- 
lusions and Hallucinations — Condition one of Partial Dementia — Cases 
Occurring at a More Advanced Age — Symptoms More Pronounced — 
In Females Absence or Irregularity of the Catamenia — Probability of 
Relapses — Importance of Avoiding a Too Early Removal from Asylum 
Life — Danger of Masturbation — Treatment — Importance of Restraints 
and Regularity of Life — Medication — Educational Influences — Occupa- 
tion, pp. 286-301 

LECTURE XVI.— SENILE INSANITY. 
Old Age — Characteristics of— Evolution No Longer Keeps Pace with Involu- 
tion — ^Etiology — Physiological and Pathological Changes in Brain and 
Nervous System — Diminution of Functional Activity — Vascular Changes 
— Nerve-cells — Mental Symptoms — Impairment of Perception — Excite- 
ment — Loss of Memory — Illusions — Depression — Physical Symptoms — 
Three Varieties — Senile Dementia — Senile Mania — Senile Melancholia — 
Cases Illustrative — Suicidal Tendencies — Treatment — Should Such Cases 
be Removed to an Asylum? — Testamentary Capacity, . . . pp. 302-321 

LECTURE XVII.— CLIMACTERIC INSANITY. 
^Etiology — The Epochs of Life — Relation to the Period of Involution — De- 
pendent Upon Physical Changes in the System — Diminution of Nerve 
Energy — Indifference — Loss of Appetite — Absence of Good Feeling — Pro- 
found Change in the Female System — Change in the Channels of Mental 



CONTENTS. XV 

Activities and Sympathies — Changes in the Processes of Elimination — 
The Cessation of the Catamenia — Heredity— Symptoms — Melancholia — 
Case i — Conditions of Depression — Abnormal Sensations — Loss of Flesh 
— Recovery — Case 2 — Mother Insane — Very Suicidal — Convalescence — 
Recovery After Four Years — Delusions — Hallucinations — Physical Symp- 
toms Present — Cases 3 and 4 — Differentiated from Melancholia at After 
Periods of Life — Prognosis — Sixty Per Cent, of Cases in the Retreat Re- 
cover — Length of Time — Permanency of Recovery will Depend Largely 
upon the Antecedents of the Case — Treatment, pp. 322-340 

LECTURE XVIII.— INSANITY OF THE PUERPERAL 
PERIOD. 

Insanity of Pregnancy. 

Importance of — Insanity of Pregnancy — ^Etiology — Intimate Relation between 
the Brain, the Stomach, and Sexual Organs — Craving for Particular Arti- 
cles of Food while in the Pregnant State — Heredity — Tables of Cases 
in the Connecticut Hospital and the Retreat —First Pregnancies — Symp- 
toms — Puerperal Insanity Proper — More Frequent in First Labors 
between Thirty and Forty Years of Age — Frequency of in Scotland — 
Character of Blood in Puerperal Insanity — Symptoms, Primary and 
Secondary — Hallucinations — Homicidal and Suicidal Tendencies — Con- 
valescence — Age — Table of Thirty-nine Cases in Reference to Recoveries, 
Ages, and Time under Treatment — Cases, pp. 341-362 

LECTURE XIX— INSANITY OF THE PUERPERAL PERIOD. 
(Concluded.) 

Treatment of Puerperal Insanity, Local and General — Insanity of Lactation — 
^Etiology — Period of Lactation — Influence of Prolonged Lactation — 
Modes of Living — Accidents and Complications at Time of Labor — 
Effects Upon the Blood and Nervous System — Symptoms — Suspicion — 
Depression — Morbid Impulses — Sexual Excitement — Hallucinations — 
Physical Condition — Tables of Cases at the Retreat and the Connecticut 
Hospital — Illustrative Case — Prognosis Generally Favorable — Of Fifty- 
four Cases, Thirty-nine Recovered — Treatment, pp. 363-376 

LECTURE XX.— INSANITY OF MASTURBATION. 
.Etiology — Effects of Sexual Derangement upon the Mind — Anxiety — Seminal 
Emissions — Neurotic and Sanguine Temperaments — Heredity — In Cases 
of Adolescent Insanity Masturbation is Often a Consequence Rather than 



XVI CONTENTS. 

a Cause — Symptoms — Debility — The Circulation — Appetite — Seclusion — 
Depression — Irritability — Cases — Diagnosis — Religiosity — Dislike of the 
Opposite Sex — Tendency to Seek Isolation — Short Periods of Self- 
importance — Prognosis — Treatment — Importance of Labor in the Open 
Air > etc., . . . ' pp. 377-391 

LECTURE XXL— EPILEPTIC INSANITY. 
Epilepsy and Insanity — Characteristics of Epileptics — Tendencies to Mental 
Derangement — Responsibility of Epileptics — Epileptic Neurosis— Charac- 
teristics of — Symptoms of Epilepsy — The Aura Epileptica — Phenomena 
Attending It — Hallucination of Any of the Special Organs of Sense — A 
Case — Swedenborg — The Aura May Affect both Sight and Hearing — 
A Case — " Petit Mai " — Symptoms of — Age — " Grand Mai" — Symptoms 
of — Derangement of Mind — " Epileptic Fury," pp. 392-406 

LECTURE XXII.— EPILEPTIC INSANITY. (Concluded.) 
Tendency Toward Dementia — Loss of Memory and Judgment — Case of 
Napoleon — Religious Emotions in Epileptics — Amorous Propensities — 
Religious Excitement — Dancing Mania — Acts of Great Violence May or 
May not be Connected with Convulsions —Two Cases — Homicidal Vio- 
lence — Cases — Prognosis — Pathology — Treatment, . . . pp. 407-420 

LECTURE XXIII.— ALCOHOLIC INSANITY. 
Physiological Effects of Alcohol — Modification of — Per Cent, of Alcoholic 
Insanity — Statistics — Acute Alcoholic Insanity — Symptoms — Illusions — 
Hallucinations — Attention — Temperature — Termination — Examples — 
Treatment — Chronic Alcoholic Insanity — Symptoms — Irritability — -In- 
somnia — Loss of Memory — Paresis of Muscular System — Suspicion — 
Hallucinations — Cramps — Hyperaesthesia — Gastritis — Epileptiform Seiz- 
ures — Delusions — Examples. — Pathological Anatomy, . . . pp. 421-438 

LECTURE XXIV.— ALCOHOLIC INSANITY. (Concluded.) 
Alcoholic Paresis — Diagnosis of — Character of Mental and Physical Symptoms 
Contrasted — Peripheral Neuritis — Hyperesthesia — Treatment — Morphin- 
ism — " The Opium Habit " — Increase of — Mode of Invasion — Dose — 
Idiosyncrasies — Hypodermic Use of Morphine — Symptoms — Feelings of 
Exaltation Followed by Those of Depression — Increase of Dose Neces- 
sary — Loss of Memory and Moral Tone — Effects Upon Nerve Cells and 
the Sensory System of Nerves — Prognosis — Treatment, . . pp. 439-449 



CONTENTS. XV11 

LECTURE XXV.— GENERAL PARESIS. 
Synonyms — Importance — Definition — Etiology — Sex — Age — Heredity — So- 
cial Position — Locality— Statistics : I. In New England Institutions; 2. 
New York Institutions, Michigan Institutions — Comparison of the Different 
Sections, Different Nationalities, and Races — Sexual Indulgence— Table 
of Causes from Reports of the Commissioners of Lunacy in England — 
Syphilis — Intemperance in the Use of Alcohol — Acquired or Inherited 
Tendency — Symptoms : I. During the Initial Period — May be Those of 
Elation or Depression — Peculiarities of Mental and Physical Symptoms 
in Both These States — Duration of Initial Period, pp. 450-468 

LECTURE XXVI.- GENERAL PARESIS. (Continued. 
Symptoms Become More Pronounced in Character — Increase of Irritability and 
Excitability — Egotism — Self-confidence — Extravagance of Projects — 
Sexual Excitement — Change in Moral Character — Failure in Memory — 
Mental Obtuseness — Insomnia — Depression not Unfrequently Present 
— Physical Symptoms — Vertigo — Incoordination of Gait — Tongue — 
Articulation — Spinal Symptoms — Disturbances of Circulation — Importance 
of Recognizing Early Symptoms — Symptoms of Pronounced Period 
— Excitement — Impairment of Judgment — Dementia — Memory — Atten- 
tion — Inability to Combine Concepts — Delusions of Great Wealth and 
Importance — Hallucinations — Emotional States, pp. 469-483 

LECTURE XXVIL— GENERAL PARESIS. (Continued.) 
Depression — Much Less Common During the Pronounced Period than Exalta- 
tion and Elation — Melancholic Symptoms May be Present — Periods of 
Excitement — Illustration — In Some Cases Neither Excitement nor Depres- 
sion Exist — States of Elation May become Changed by Suggestions — Ex- 
travagance of Delusions — Physical Symptoms of the Pronounced Period — 
Tongue — Lips — Muscles of the Face — Handwriting — Epileptiform Seiz- 
ures — Corpulence — Gait — Eye Symptoms — Period of Boasting — Increase 
of Dementia — Paralysis — Sphincters — Convulsive Seizures — Bed-sores — 
Bone Fractures — Case, pp. 484-506 

LECTURE XXVIII.— GENERAL PARESIS. (Concluded.) 
Remissions — Duration of — Relapses — A Case — Duration of Disease; Average 
from three to Four Years — Diagnosis — Characteristic Symptoms — Im- 
portance of Physical Symptoms in Determining Doubtful Cases — These 
May Precede or Follow Mental Symptoms — Maniacal State of Alcoholism 



XV111 CONTENTS. 

— Chronic Lead Poisoning — Morbid Anatomy — The Whole Cerebro-Spinal 
and Sympathetic Systems Affected — Diminution in Volume of Brain — 
Adhesion of the Pia to the Gyri — Disease of Vessels and Nerve-cells — 
" Spider-like" Cells — Ventricles — Spinal Cord — Treatment — Prognosis — 
Importance of Early Treatment and of Removal from Home to an Insti- 
tution — Medication — Bromides — Tonics — Laxatives — Hypnotics — Lo- 
tions — Water-bed, etc., pp. 507-527 

LECTURE XXIX.— ACUTE DELIRIUM (TYPHOMANIA.) 
POST-FEBRILE INSANITY. 
Historical References — The Term Typhomania — Definition — ^Etiology — Emi- 
gration — Exposure to High Temperature — Physical, Mental, and Alco- 
holic Excesses — Symptoms — Develop Rapidly — Indications of Fatigue — 
Insomnia — Delirium, Character of — Subsides in about Two Weeks, and 
is Succeeded by Conditions of Semi-stupor — Countenance — Pupils — 
Tongue — Intolerance of Food and Drink — Pulse — Circulation — Vesicles 
— Examples — Morbid Anatomy — Diagnosis — Treatment — Post-febrile In- 
sanity — General Remarks on the Delirium of Fevers — Trousseau — 
Delirium in Children — Delirium in Typhoid Fever not of Serious Import 
— Three Forms of Mental Impairment Following Fever — Relative Im- 
portance of Each — ^Etiology — Unwise Treatment of Fevers in Reference 
to Feeding — Symptoms — May be of an Excited or Depressed Type — 
Physical Conditions are those of Anaemia and Perverted Nutrition — Dr. 
Hurd's Twenty-three Cases — Cases Following Surgical Operations — 
Hochwart's Thirty-one Cases Following Eye Operations. — The Thirty-five 
Cases of the Retreat — Prognosis — Generally Favorable — Treatment. 

pp. 528-552 

APPENDIX. 

Extracts from the Laws of the Different States and Territories of the United 
States which relate to the General Care of the Insane, . . .pp. 555-627 

Index, pp. 629-636 



Lectures on Mental Diseases, 



LECTURE I 



INTRODUCTORY. 



THE PHYSICAL BASIS OF THOUGHT. 

Advance in the Study of the Minute Anatomy of the Brain — Lobes, Convolu- 
tions and Fissures of the Brain — The cortex cerebri — Grey matter of the 
Brain — Central Ganglia — Optic Thalami — The Striate Bodies — Two Kinds 
of Nerves, the Sensory and Motor — Anatomy of the Nerves — Anatomical 
Arrangements of the End Organs of Sense — Functions of the Nerves — 
The Transmission of Irritations to and from the Cortex — Functions of 
Nerve-cells and Nerves Contrasted — Transformation of Irritations into 
Sensations — The Thought-process in its Relation to the Molecular 
Activities of the Nerves and Cells of the Cortex— The Evolution of Sensa- 
tions, Perceptions, Thoughts, Purposes, and Opinions— The Mind, Per- 
sonality, Ego — Views of Different Authors — Nerve-energy — Agents which 
Affect it — Measurement of its Degree of Action — Derangement of its 
Normal Action the Initial Element of Insanity. 

No greater advance has been made in the study of the 
minute anatomy of any organ or part of the system within 
recent years than in that of the brain and spinal cord. This 
has been stimulated in the first instance by the desire to 
understand more fully and perfectly the relation which 
had long been surmised to exist between disordered mental 



IO LECTURES ON MENTAL DISEASES. 

states and diseases of the brain, but which it had never 
been feasible to demonstrate. The microscope and the dis- 
covery of means whereby brain tissue can be prepared for 
observation, have now made it possible to study some of 
the pathological conditions to which it is subject. It, there- 
fore, may be regarded as important, in introducing you to 
the study of mental diseases, to call your attention to some 
of its component parts and ganglia; and also to allude to 
the complexity and arrangements of the elements of which 
it is composed. While a resume of the knowledge of the 
anatomy and physiology of the whole nervous system is 
most desirable and important as preliminary to the study 
of insanity, yet the subject is too large for a lecture. An 
attempt at a complete presentation would necessarily cover 
too much of the space allotted to me in these lectures. 
It will, therefore, be my purpose to present only the 
briefest enumeration and description of some of those parts 
of the brain and nerves which are supposed to be most 
intimately concerned, through their physiological functions, 
in mental processes. For further and more perfect account 
of the anatomy and physiology of the brain and spinal 
cord, I refer you to the works of Obersteiner, Hughlings 
Jackson, Bevan Lewis, Meynert, Luys, and others, whose 
recent studies have so greatly enriched our knowledge of 
this subject. 

The nervous system may, then, for convenience of study, 
be divided into two portions : First, the encephalon, or brain 
proper, with the spinal cord ; and second, the nerves which 
pass to and from the brain to all portions of the general 
system, covering every point upon its whole surface. The 
brain itself is composed of two hemispheres, symmetrically 
constituted and arranged, which are united by a band of 
white fibres constituting the commissures, by means of 



THE PHYSICAL BASIS OF THOUGHT. 



I 1 



which they are brought into the most intimate connection, 
establishing thereby a sort of double brain. Each hemi- 
sphere is mapped out into lobes and convolutions, which are 
bounded more or less definitely by lines or fissures. While 
the arrangement of the fissures is not invariable, yet it is 



Fig. i. 




Side View of the Brain. 



generally so definite as to be easily recognized, especially 
in the more important ones. The principal fissures are : I. 
Fissura Sylvii or the great lateral fissure. 2. Sulcus Ro- 
landi, or the transverse fissure. 3. Fissura occipitalis, or 
the perpendicular occipital fissure. 4. Fissura calcarina, or 



12 LECTURES ON MENTAL DISEASES. 

the horizontal occipital fissure. Besides these there are other 
minor or secondary fissures. The frontal lobe has four of 
these fissures, two of which are perpendicular, and two lon- 

FlG. 2. 




View of the Brain from Above. 



gitudinal ; and also four convolutions ; the anterior central, 
the middle, the lower, and upper longitudinal. The parietal 
lobe is divided into the superior and inferior, and has four 



THE PHYSICAL BASIS OF THOUGHT. 1 3 

convolutions, viz. : the posterior central, the parietal supe- 
rior, the inferior, and superior parietal arches. The temporal 
lobe has three quite definite lines or fissures, and four con- 
volutions : the superior and inferior, the middle, and vertical, 
The occipital lobe is nearly triangular in form, and also has 
four fissures and four convolutions, viz. : the arcus occipitalis, 
and the three convolutions of Ecker. 

Proceeding on a radical and developmental basis, the brain 
has been otherwise divided into the prosencephalon — the 
fore-brain ; the thalamencephalon — the between-brain ; 
the mesencephalon — the mid-brain; the epencephalon — 
the hind-brain; the metencephalon — the after-brain, or the 
oblongata. The first of these, or the great brain, will 
be referred to hereafter. The 'tween brain includes, as its 
most important parts, the optic thalami, the optic tracts, the 
corpora mammillaria, the two corpora geniculata, and the 
third ventricle. The mid-brain contains the great cerebral 
peduncle, and the corpora quadrigemina. The hind-brain, 
or the cerebellum, comprises a large body of crossing fibres 
and is covered, like the fore-brain, with grey matter. Nu- 
merous superficial fissures cover its external surface ; they 
are irregularly arranged and of unequal depth, and serve to 
divide it into several more or less distinct lobes. These 
fissures impart to the organ its characteristic appearance. 
The after-brain, or the medulla oblongata, is the intermediate 
body uniting the spinal cord and the brain, and measures 
about three cm. Its dorsal surface is nearly covered by 
three sulci which extend up from the cord, and serve to 
bring into view more or less distinctly certain prominences, 
the most prominent of which is the inferior olive. 

There are two kinds of matter which enter largely into 
the constitution of the brain, and which are quite distinct 
from each other in appearance and character — the grey and 



Fig. 3. 




a. Gyrus fornicatus. 

b. Corpus callosum. 

c. Septum lucidum. 

d. Columnar fornicis. 

e. Corpus striatum. 
/. Stria terminalis. 
g. Thalamus opticus. 
h. Pulvinar. 

i. Brachium conjunctivum anti- 

cum. 
j. Peduncular cerebri. 



k, I, m. Crus cerebelli. 
n. Origin of the abducens. 
o. Ala cinerese. 
p. Obex. 

q. Funiculus gracilis. 
r. Funiculus cuneatus. 
j. Clava. 
t. Calcar avis. 
u. Hippocampus. 
v. Caudate nucleus. 
■w. Corpus geniculatum mediale. 



.v. Thalamus opticus. 
y. Capsula interna. 

0. Claustrum. 

1. Nucleus lentiformis. 

2. Island of Reil. 

3. Capsula externa. 

4. " interna. 

5. Caput nuclei caudati. 

6. Cornu anticum. 

H 



THE PHYSICAL BASIS OF THOUGHT. 1 5 

white. The characteristic element of the former is the nerve 
cell, of the latter medullated fibres ; while the function of 
the former is the origination or rather the transformation, 
and that of the latter the transmission of nerve im- 
pulses. Grey matter covers the whole exterior and upper 
convex surface, and is termed the cortex cerebri. It is some- 
what unevenly arranged ; is enclosed in two or three mem- 
branes on the external surface, and passes into the different 
sulci and the median division, until it reaches the commis- 
sural fibres. 

This cortex, composed so largely of grey matter, is of the 
highest significance to the student of mental diseases, as it 
constitutes the great centre to which all influences or im- 
pressions are radiated from the periphery, and from which 
they are again reflected outward. It comprises those com- 
binations of cells, fibres, and blood-vessels, whose physiolo- 
gical function constitutes so important an element in the 
evolution of mental activities. It, with other agglomera- 
tions of ganglia composed of grey matter, constitutes the 
sub-structure, the physiological derangements and changes 
of which produce the several genera of mental disorders 
which are grouped under the term insanity. Its depth 
varies, as does also the depth of the sulci or fissures which 
intersect it, in different orders of animals and in different 
individuals of the same order. 

The numerous and intricate sulci into which the grey 
matter dips, serve to very largely increase its extent of surface, 
the material being, as it were, doubled up on itself; whereas, if 
the grey matter was simply extended in a smooth form along 
the concave cavity of the cranium, a greatly less extended 
surface of it could be enclosed within. In the monkey and 
the higher orders of the mammalia, below the genus homo, 
these sulci are much more rudimentary, and only in the 



1 6 LECTURES ON MENTAL DISEASES. 

human species do they become complicated and fully pro- 
nounced. This fact appears to confirm the theory that in 
some manner the higher degree of intelligence depends upon 
the superficial area, as also upon the depth of the grey 
matter. This view is further strengthened by the fact that 
in imbeciles, idiots, and some classes of criminals, these 
sulci are much more superficial than in the higher and more 
intellectual classes of persons. 

In passing downward from the superior surface of the 
grey substance comprising the cortex, we perceive that it 
varies to some extent in depth in the different regions of 
the brain, and is arranged in more or less distinctly-marked 
concentric layers. (Meynert.) In the convolutions are 
found no less than five of these layers, the first of which is 
made up largely of connective tissue, with a small number 
of quite irregularly shaped cells scattered through it, but 
which are found more often near the external surface of the 
layer, and with extensions downward. In it are also found 
fine medullated and non-medullated nerve fibres and blood- 
vessels. 

The second layer is much more sharply bounded, and is 
filled with large numbers of a peculiar triangular or pyra- 
midal shaped cell, which is termed the nerve cell. These 
cells vary considerably in size, and have small processes 
which radiate from their sides and angular points. In form 
and general appearance they differ from the cells of any 
other portion of the system, and all have their apices turned 
toward the surface of the convolutions, and are arranged 
in layers more or less parallel with each other. They are 
smaller than those in the layer next below, and have been 
called the " small pyramids." 

In the third layer these cells become four or five times 
larger than those of the second layer, with a diameter from 



THE PHYSICAL BASIS OF THOUGHT. 



17 



Fig. 4. 



Fig. 5. 



Fig. 6. 




.; ■•■ ■ /; - ,-.. . ^;:.,;,:; 



J~r-r:- 




m 



mm 

mm 



•HZ 



3 



mm 

mil 



Fig. 7. 






s* S> 









47; 



Sections through the Cortex Cerebri, Showing the Cells of the 
Different Layers. 



i8 



LECTURES ON MENTAL DISEASES. 



one twelve-hundredth of an inch to one fifteen-hundredth, 
and are more widely separated from each other in conse- 
quence of the multitude of fibres which pass everywhere 
between them. Indeed, they appear to be enclosed in a 
network of fibres and blood-vessels. They all have several 
processes passing in different directions from those points 
which are more or less angular, together with a kind of 



Fig. 8. 




Cortex of the Gyrus Cinguli. 

Cell, corpus callosum; Stlm,sXx\2. longitudinalis medialis. 



fringe-work extending along the whole border of each cell, 
and more especially at the points where the nerve-fibres 
appear to enter or leave them. The larger nerve-fibres 
appear to connect with the cells at both the lower and 
upper points, and from the lower pass to the upper spaces 
where they interlace with each other, and then again pass 
downward. 



Fig. 9. 




y 



/ 



Fig. 10. 





Cell from the Spinal Cord. X I 5°- 



Pyramidal Cell from the Cortex. X 2 °°. 



20 LECTURES ON MENTAL DISEASES. 

They have nuclei which are also pyramidal in form, and 
also nucleoli which are surrounded with layers of proto- 
plasmic material, which is more dense than that lying near 
the surface of the cell. These nucleoli are "also divisible 
into secondary filaments" (Luys), and for aught we know 
now to the contrary, may be found to have a most compli- 
cated structure. 

In the fourth layer there appears to be an almost total 
absence of these pyramidal cells, and in their place there is 
observed a large quantity of elements irregularly shaped, 
which is termed the " granular formation." These elements 
are larger in the upper portion of the layer and are grouped 
irregularly into clusters. Near the lower portion of the 
layer they become smaller and often isolated. 

Below this is the fifth layer, which is not very definitely 
bounded, but has a considerable number of cells, some of 
which, especially those in the upper portion of the layer, 
are pyramidal in form, while those in the lower portion and 
near the medullary substance of the brain are long and 
spindle-shaped. (Meynert.) They also send out processes 
or fibres toward the granular elements of the fourth layer. 

In our progress downward we next come to the medul- 
lary substance, which contains more or less of the spindle- 
shaped cylinders, with fibres or bundles of them extending 
in the same general direction as those of the layers already 
described. There exist also, associated or intermingled 
with these fibres, " branching cells," in varying numbers 
according to locality. Below this, though there exists no 
sharply defined line of division, is the white substance of the 
brain, which is filled with granular matter and nerve-fibres, 
and furnishes a cushion, as also a support, for the innumer- 
able medullated nerve-fibres which pass through it from 
the cortex to the periphery. 



THE PHYSICAL BASIS OF THOUGHT. 21 

About the basal centre of the brain we find another 
acra-reoration of grey matter, though arranged in a very 
different manner. In a general way it may be said to be 
made up of several aggregations of ganglia, the larger and 
more important of which appear to be the optic thalami, 
the corpora striata, the corpora quadrigemina, and the 
pineal gland. 

The optic thalami are situated in the rear of the striate 
bodies, and directly above where the spinal cord enters 
into and becomes part of the brain. They are broader 
behind than on the anterior end, and have a form some- 
what like the shape of a wedge. The surface of a sec- 
tion made across the body of the ganglia would present 
three angles more or less distinctly acute. They are com- 
posed largely of grey matter, arranged in layers, which is 
made up of nerve-cells, medullated fibres, and blood-vessels. 
These cells are grouped together in different portions of 
the thalamus, and appear to form centres around which the 
medullated fibres gather, and are radiated to the several 
portions of the cortex — anterior, posterior, and lateral. The 
nerve-fibres reaching the ganglia from different directions 
appear to cross from side to side and end to end, and form 
more or less distinct planes extending across the thalamic 
body. Luys claims that they are each composed of or 
contain four small ganglia. These several ganglia would, 
therefore, become a sort of terminal centre or pivot, around 
which revolve all the attractions and reflections of the 
nerve-fibres, which arrive here from all portions of the 
body, one of which is found to be connected directly with 
the olfactory nerve, and therefore receives all impressions 
made upon it ; another with the optic nerve, and therefore 
receives and transmits all impressions produced on it. The 
third is intimately connected with the nerves of general 



22 



LECTURES ON MENTAL DISEASES. 



sensation, which reach it through the spinal cord, while 
the fourth receives the impressions communicated by the 
auditory nerve. In this way it. appears that there exist 



Fig. ii. 




Section through the 'Tween-brain beneath the upper Surface of 
the Optic Thalamus and the Nucleus Caudatus. The Thala- 
mus, the Nucleus Caudatus and the Immediately Surrounding 
Parts are Shown. 

Com, commissura mollis; Vj, third ventricle; Fcl, columna fornicis ; Spl, septum pellu- 
cidum ; Via, anterior horn of lateral ventricle ; Gcc, genu corporis callosi ; Pdc, pedun- 
culus pinealis: Glp, glandula pinealis; Qp, posterior corpora quadrigemina; Qn, 
anterior corpora quadrigemina; gh, ganglion hebenulse; Nc, nucleus caudatus; Sic, 
stria cornea ; Na, nucleus anterior; Nl, nucleus lateralis. 



separate and, in some measure, independent centres for the 
reception and transmission of impressions received through 



THE PHYSICAL BASIS OF THOUGHT. 23 

the different channels of communication. For instance, 
the ganglia which receives the fibres of the optic nerve 
may become inoperative, from the effect of disease, while 
those of hearing and general sensation may remain sound, 
and, vice versa, those of hearing and feeling may become 
disordered and that of sight remain sound ; whereas, if the 
nerves of all these channels of communication were to 
centre in one ganglion, a disorder of this one would at 
once close up all means of communication with the world 
outside. 

These ganglia, however, are not supposed to be the 
terminal points of the nerve-fibres, which reach them from 
all parts ; on the contrary, the fibres appear to pass through 
or around them, and are found emerging from them toward 
the nerve-cells we have already described as largely com- 
posing the grey matter of the cortex of the brain. This 
view of Luys has been regarded by some anatomists of the 
brain as somewhat fanciful and has not yet been fully con- 
firmed ; of its general accuracy, however, there can be little 
doubt. Dr. W. Bevan Lewis,* while appearing to be some- 
what guarded in his statement, says that " radiative fibres in 
coarse fasciculi are seen passing from the whole extent of 
the upper margin of the thalamus, either directly outward 
toward the parietal lobe or arching upward toward the 
occipital region. These fasciculi consequently form the 
outer wall of the lateral ventricle in their course toward 
the parietal lobe. If the scalpel divide across parallel to 
the direction of the stria cornea, the blade passes directly 
into the internal capsule, and it becomes evident that the 
outer obliquely-placed surface of the thalamus rests upon 
the internal capsule as upon a couch, and gives off from the 

* " Text-Book on Mental Diseases," pp. 43, 45. 



24 LECTURES ON MENTAL DISEASES. 

whole of its outer aspect medullated fibres, which enter 
into the constitution of this capsule, and then spread as 
coronal radiations to the various districts of the cortex of 
the parietal and temporo-sphenoidal lobes.. * * * The 
zonular layer of the thalamic capsule receives fibres from 
almost every region of the brain — the frontal, parietal, 
temporo-sphenoidal, and occipital lobes, and the mesial 
aspect, or gyrus fornicatus, as well as the retina." 

In like manner fibres radiate from other bodies of grey 
matter; the caudate nucleus, the lenticular nucleus, and 
from the olfactory bulb. 

The corpus striatum has already been referred to in con- 
nection with the optic thalamus and, indeed, forms a sort of 
complement to it. It is situated a little laterally and ante- 
riorly to the thalamus, and consists of a reddish, dark, ovoid 
body, with its largest portion to the front, and receives the 
converging nerve-fibres which come to it from the various 
regions of the cortex of the brain. It is supposed that these 
fibres terminate in this body, or at least they have not yet 
been traced, as passing through it. But there are others 
emerging from the under-side of it, which pass down and 
out to the various portions of the body in some such man- 
ner as do those which pass from the thalamic ganglia to the 
various regions of the cortex. If these views shall be 
verified by further researches of anatomists, this body may 
be supposed to serve as a sort of station or halting place 
for all impressions which have been received and trans- 
mitted through the sensory nerves to the optic thalami, and 
to other ganglia of grey matter in its vicinage, thence up to 
the nerve-cells of the cortex of the brain, and again down 
to this and other bodies of grey matter. Here they are 
supposed to be reinforced, and again become materialized 
by being converted into motor action ; that is, they are sent 



THE PHYSICAL BASIS OF THOUGHT. 25 

out in the form of speech, movement, or action in some 
direction. 

The nerve-cells which are found in these ganglia, and, 
indeed, in all other parts in which fibres and grey substance 
are endowed with special functions (according to van der 
Kolk),have a character peculiar to themselves in their form, 
size, and structure, as also in their relations and connections 
with other cells. Nerve- cells also differ very materially in 
size according to the ganglia and the regions of the cortex 
in which they are found, and the character and importance 

Fig. 12. 






i---v---l^- .,.C/: I 1 .0 • ; ' ! /iUrV- 





Figure Showing the Relation of the Nucleus Caudatus to the 

Cortex. 

of the functions over which they preside, and possibly the 
length of time they have existed. 

It has already been noticed that the nerve-cells which 
are found in the different layers of the cortex vary very 
considerably in size, the larger portion of those found 
in the second and fourth layers being much smaller than 
those which are found in the third layer. As the layer con- 
taining the larger cells lies between the others, this differ- 
ence in size cannot arise from their location, or upon advan- 
tages secured through nutrition ; and as they are arranged 
3 



26 LECTURES ON MENTAL DISEASES. 

upon a system which is found to invariably obtain in the 
human brain, it is reasonable to look for the explanation in 
the degree or quality of function. The arrangement of the 
cortex in more or less definitely bounded layers, would also 
indicate diversity of function ; indeed, it is difficult to con- 
ceive of any other cause for such diversity in the anatomical 
arrangement of the cortex except this, as nature always 
proceeds upon the simplest plan which is adequate to the 
discharge of function. 

The fact, therefore, that the cortex cerebri presents in 
its constitution such complexity of arrangements and such 
diversity in its elements, points to diversity of function, 
in quality, if not in quantity. Dr. W. Bevan Lewis calls 
attention to the probability that the larger nerve-cells in the 
motor region of the cortex are, by their medullated fibres, 
connected with and preside over the ganglia of the spinal 
cord which govern the movements of the lower extremities. 
The fact that this influence has to pass over such a long 
distance, as compared with that which passes to the ganglia 
located at the cervical portion of the cord, would indicate 
the requisition of a larger amount of function. This will 
also vary in size to some extent, according to the height 
and physical constitution of the individual. Larger muscles 
also require for their functional activities more of nerve 
energy than small ones. 

A similar view was suggested some years ago by Dr. 
Hughlings Jackson.* This is as follows: "I have sug- 
gested that the size and shape of cells, as well as their near- 
ness to the tumor or other source of irritation, will have 
to do with their becoming unstable ; other things being 
equal, the same quantity of matter in many small cells will 

;: " " On Temporary Paralysis after Epileptiform and Epileptic Seizures." 



THE PHYSICAL BASIS OF THOUGHT. 2J 

present a vastly greater surface to the contact of nutrient 
material than the same quantity in one large cell. I have 
also suggested that small muscles, or, more properly, move- 
ments, which require little energy for the displacements 
they have to effect (those of the face and hands in touch, for 
example) are represented by small cells. Such movements 
are rapidly changing during many of the operations they 
serve — in writing, for example — and require repetitions of 
short liberations of energy and necessitate quick recupera- 
tions of the cells. Movements of the upper arm are, in 
comparison, little changing, and require persistent, steady 
liberations of energy." 

Before referring further to the peculiar manner in which 
these cells act in connection with the nerve-fibres connected 
with them, it may be necessary to refer somewhat in detail 
to the structure and arrangement of the nerves themselves. 
There exist two kinds of nerves, first, the excito-motor, or 
nerves of sensation; these all convey impressions from the 
periphery of the body to the spinal cord, and thence up to 
the aggregations of ganglia which have been already re- 
ferred to. Second, the motor nerves, which emerge from the 
various centres of the cortex and pass down through the cor- 
pora striata and other basal ganglia ; or according to some 
authorities, directly through the internal caspule and the 
pyramidal tracts of the pons and medulla, and in their turn 
are distributed through the cord and convey sensations, 
after they have become materialized, back to the periphery 
of the body, eventuating in speech or motion. All medul- 
lated nerve-fibres have axes which are covered with two or 
more envelopes or coats, which appear to serve the purpose 
of isolating them from the parts which lie adjacent. They 
arise in connection with the cells of the grey matter, and 
extend to all portions of the body. They compose largely 



28 



LECTURES ON MENTAL DISEASES. 



the white substance of the brain and spinal cord. The 
axis-cylinder of the nerve appears to be the essential 
portion in the transmission of irritations received upon 
the peripheral terminations, and is composed of " protein 



Fig. 13. 



Fig. 14. 




<l 



I 



Peripheral Nerve Fibres of 
the Frog. X 1000. 

Nerve Fibres from 
the Sciatic of 
the Frog. X 4°°- 



Fig. 15 



m 






I! 



Medullated Fibres. X 2 °°- 



substance " and fine fibrillar, so arranged as to be suscep- 
tible of isomeric transformation from one state to another. 
It is the axis portion of the nerve which becomes connected 
directly with the terminal vesicles, and also with the percep- 



THE PHYSICAL BASIS OF THOUGHT. 29 

tive cells and sensory ganglia of the grey matter at the 
base of the brain. 

In order to indicate more fully the manner in which 
irritations are received upon and transmitted through the 
nerves to the basal ganglia, where they become converted 
into sensations, it becomes necessaiy to trace out more fully 
the peculiarity of their terminations. This varies to some 
extent in the different portions of the cutaneous surface. 

In the skin of the fingers and toes are found small bodies 
called tactile corpuscles, imbedded in the immediate sur- 
face, which are filled with granular matter, easily compres- 
sible and mobile in character, to which the peripheral end 
of the nerve-fibre becomes united after passing around it. 
Whenever pressure or friction is effected on these surfaces 
and the corpuscles become affected, they communicate this 
motion to the nerve-fibres with a greater impulse than they 
could receive if they were only imbedded in the general 
mass composed of a much more stable tissue. In some 
other localities the surfaces of which are subject to frequent 
friction or pressure, such as the surfaces of the arms and 
legs, these minute corpuscular bodies have not been found. 
According to Mr. Herbert Spencer, on these surfaces each 
of the short hairs, which grow in greater or less abundance, 
acts as a "tactile multiplier," greatly increasing the effects 
of such pressures as are brought to bear upon them. 

But it is more especially in connection with the other 
special organs of sense, that the peculiar connection of the 
peripheral termination of nerves with the external surface 
has been studied and demonstrated most perfectly. For in- 
stance, the vibrations of the atmosphere caused by the action 
of bodies upon one another are not heard at the perceptive 
cells at the basal ganglia as sound. These vibrations are sup- 
posed first to affect the cells which are imbedded in the liquid 



30 LECTURES ON MENTAL DISEASES. 

of the internal chamber of the ear, and these cells communi- 
cate the impressions of irritations to the auditory nerve, 
which in turn conveys them to the perceptive ganglia at 
the base of the brain. Another theory is that the vibra- 
tions of the air, according to their rate, set in motion the 
different elements of the organ of Corti, which communi- 
cate the impulse to the special fibres with which they are 
connected. 

These numerous cells are doubtless connected, either 
directly or indirectly, with the numerous nerve-fibres of 
the auditory nerve, thus causing the peculiarity of tone for 
which it is adapted by its construction ; whereas, if all 
vibrations were to impinge directly upon the auditory nerve, 
and be conveyed at once to the basal ganglia, they would 
eventuate in a multitude of undifferentiated sounds. That 
these cells and their normal connection with the cells of 
the nerve are essential to hearing becomes evident when- 
ever they become injured by disease or force. Vibrations 
communicated through any other channel to the sense- 
centres are not perceived as sounds, though they may be 
as pain. It therefore becomes evident that we do not 
hear directly actually the vibrations of air, but simply the 
molecular motion of the perceptive cells. It is the activity 
of these cells which we hear as sound, when it is caused 
by irritations acting within the brain itself, as in hallucina- 
tions of hearing. 

An arrangement of a similar nature, though differing in 
the detail of construction, exists in the eye. It is a familiar 
experience to every one that flashes of light are perceived 
in the cells of perception when in reality no light has 
reached the posterior portion of the eye ; the flash of light 
has been caused by a sudden blow or pressure on the head, 
and the expression, " I will make you to see stars," has 



THE PHYSICAL BASIS OF THOUGHT. 3 1 

passed into a proverb. Behind the retina, or rather as a 
part of it, a superficial layer of cells or rods is arranged, 
the axis of each one of which runs parallel with the rays 
of light as they impinge upon them. These minute lines 
or rods become at once excited to molecular activity by 
the effect of the particles of light, which activity communi- 
cates the influence and stimulates the fibres of the retina. 
It is, therefore, only in an indirect manner that the retina 
is affected by light, and it is, in fact, quite insensible to its 
direct influence. When the nerve-fibres of the retina have 
become thus indirectly excited, they communicate through 
the optic nerve the effect of the irritation in the form of 
molecular activity back to the cells or small ganglia of the 
optic thalami, where it becomes changed into sight sensa- 
tions. In this case, as in that of hearing, it is only the 
molecular change which has passed through the nerve to 
the basal ganglia which is perceived by the individual. 
The image formed on the retina can pass back no further 
on the dark passage through which the impression pro- 
ceeds. The eye may be in a perfectly normal condition ; 
its lenses, muscles, nerves, and humors may all be intact, 
so that the image is reflected upon the fundus of the eye ; 
but if the optic tract is invaded by disease, or if, for any 
cause, its ability to convey irritations and consequent im- 
pressions to the perceptive cells is destroyed or in abeyance, 
there can be no sight. Only, as in the sense of hearing, 
there may occur hallucinations which arise from centric 
irritations communicated to the ganglia of sight. 

An arrangement, differing in some of its details from that 
above described as pertaining to general sensation, and yet 
serving a similar purpose, exists in the Sclineidcrian mem- 
brane, comprising the machinery for perceiving odors. The 
peculiar epithelial cells of this membrane, which may be 



32 LECTURES ON MENTAL DISEASES. 

regarded as forming the termination of the nerve proper, do 
not lie immediately at the surface, but, on the contrary, are 
connected by means of fine nerve-fibres with corpuscles of 
granular material having a highly sensitive and unstable 
character which lie in and pervade the whole exposed sur- 
face, and whose office it is to receive and communicate the 
presence of such odors of various kinds as may reach them 
back to the peculiar epithelial cells, which in turn convey 
the impression through the olfactory nerve to the basal 
ganglia, where they become differentiated as odors. The 
delicacy and sensitiveness of these corpuscular bodies, or 
of the communicating fibres, differ very largely in different 
persons, and still more largely in different species of animals. 
While some individuals are able to perceive only the more 
highly concentrated and pungent odors, others perceive the 
slightest and most delicate at once on approaching their 
presence. This is more conspicuous in respect to some 
varieties of game animals, especially the moose, whose 
organs of smell are so highly developed and enlarged as to 
enable the animal to perceive the approach of an enemy 
through long distances, and such approach is quite imprac- 
ticable except from the windward. 

Again, the nerve whose function is that of taste has a 
final termination peculiar to itself, which subserves a pur- 
pose similar to that above described as existing in the other 
special organs of sense. The small papillae of the tongue 
are covered with cells which send out a fine, thread-like 
nerve fibril, which unites the nerve of taste with an epi- 
thelial cell. By means of this anatomical arrangement, 
highly concentrated and sharp, biting fluids do not come 
directly in contact with the nerve-fibre ; and in the usual 
condition of the tongue, covered with the secretions of its 
mucous surface, do not reach even the corpuscular cells at 



THE PHYSICAL BASIS OF THOUGHT. 33 

once, or until somewhat changed in character. How far 
the differences in taste in individuals may depend upon the 
size and activity of these cells of the papillae is uncertain, 
but it is reasonable to infer that they may be, at least par- 
tially, dependent upon such differences of arrangement. 

The question arises, however, in the matter of taste as 
in that of sound, as to what causes the different kinds or 
qualities of them when perceived by the senses. The 
ultimate particles of one substance produce an effect, 
which, when communicated to the perceptive ganglia, is 
regarded as sweet ; those of another substance as sour, 
and those of a third as bitter. A certain rapidity of 
vibration in the atmosphere, when impinging upon the 
cells of the inner ear and communicated to the basal 
ganglia, produces one quality or tone of musical sound, 
another rate of vibration quite a different tone. The same 
is true in reference to the effect of different odors as they 
reach the sense-centre of smell. Now, does this difference 
of quality in taste, sound, and smell depend upon the pecu- 
liarity of movements first started in the superficial tactile 
corpuscle, or upon the peculiarity of vibration in the cells 
of the nerve-tube, which the ultimate particles of food, or 
movements of atmosphere produce in them ? Or, again, is 
there a special fibril of the nerve which alone can be affected 
or thrown into vibration by each several quality of particles, 
such as sweet, sour, or bitter, which reaches it ? Physiology 
assumes the last of these hypotheses as more fully covering 
the phenomena, under the name of "specific energy" of 
nerves. We can readily understand that a strong, bitter, 
or sour particle would produce a more profound impression 
upon the mobile granular matter of the corpuscle, and that 
it in turn would multiply this effect upon the granules of 
the nerve by means of which it is passed to the perceptive 
4 



34 LECTURES ON MENTAL DISEASES. 

centres, but that either rapidity or slowness of activity 
could be perceived by the person as sweet or sour or bitter 
is certainly not easily comprehended. And this is the most 
that we can conceive of as arising in the activity of the 
nerve-tube from the effect of different ultimate particles, 
except by the assumption of a specific energy. We may, 
however, regard it as possible that there may exist in 
the perceptive centres special cells, which can be roused into 
activity only as a particular vibration of sound, smell, or 
taste should reach them. Both these hypotheses, however, 
would only remove the difficulty of understanding how a 
character of motion can become a quality of taste, or sound, 
one step further back. The mystery remains as unsolved 
as before. 

One fact, however, becomes apparent from what has al- 
ready been observed, which is, that we do not directly per- 
ceive the phenomena of the external world. We perceive 
only such molecular activity of the cells or ganglia situated 
at the base of the brain as these phenomena are specially 
and severally adapted to, and actually do produce when 
they are brought in contact with the peripheral terminations 
of the nerves. It may also be inferred that accuracy in the 
process of observing by different individuals will depend 
largely upon the delicacy, sensitiveness, completeness, and 
functional activity of these several portions of the nervous 
system above described. Also, that in those cases in 
which persons are unable to distinguish certain colors, and 
are what is termed " color blind, " and in those persons 
who are unable to distinguish between musical tones and 
combinations of sound, it is because the tactile corpuscles, 
or perceptive cells or connective fibres are either less in 
number, inferior in size, or defective in functional activity. 
To such persons the phenomena of certain sounds and color 



THE PHYSICAL BASIS OF THOUGHT. 35 

are as if they did not exist ; and this leads to the supposi- 
tion that there may be innumerable phenomena existing 
in the world which are unknown to us, because our nervous 
systems are not so constructed or arranged as to become 
affected by them ; and that they will always remain so, un- 
less in the progress of coming ages our nervous systems 
shall become more highly organized, or additional elements 
of perception and intellection shall become evolved. 

It is, however, in the actions and reactions of the vast 
network of cells, fibres, and ganglia of the cortex which are 
brought into activity in the various processes of thought 
that the mystery of functional product becomes still 
greater. Contrasting the functions of these two great por- 
tions of the nervous system which have now been referred 
to, we observe that the nerve-cell, which is found to be so 
important an element in the cortex, is the centre of an 
active principle, and that the nerve is the channel through 
which the influence of external phenomena is conveyed to 
it, and the modified results are again discharged from the 
body. The nerve is altogether passive, and is brought into 
the exercise of function only by agencies acting from with- 
out or within. The nerve-cell, on the contrary, is the seat 
of a conscious entity, which has the capacity of attention 
and will ; it pervades the whole cerebral cortex in almost 
infinite numbers, each one of which, while it is united with 
its fellows and participates with them in a common func- 
tional activity, yet has an individual character and anatomy 
of its own. Its characteristic form, its angles, its axes, its 
projections and fibres, all appear to be renewed from time 
to time, while the individual anatomy remains unchanged ; 
and these renewals take place, not by accretion or ab- 
sorption from the surrounding tissues or blood-vessels 



36 LECTURES ON MENTAL DISEASES. 

directly, but from the results of forces acting from within 
the cell itself; that the bioplasmic material of the interior 
of the cell is constantly elaborating nucleoli, which in turn 
become nuclei, and these afterward become the cell proper, 
so that the cell never wholly dies, except from disease, 
while the brain remains in its usual state of health, or un- 
less it becomes enfeebled by age. Its waste elements, which 
are thrown off from its exterior, are constantly replaced by 
those elaborated within. 

But aside from these physiological activities and changes 
going on in the cells of the cortex, there appears to be 
another activity which is everywhere moving hither and 
thither through the cortex, apprehending, forming, and 
combining the constant stream of impressions which are 
passing to it through the avenues which reach it from the ex- 
ternal world, and those which arise in the nerve-cells from the 
stored-up experiences of the past, into thoughts, opinions, 
memories, and purposes. As these impressions reach areas 
of the cortex, they give rise to mental activities the nature 
of which will be determined largely by the inheritance, 
education, and previous experiences of the individual ; and 
these thoughts and ideas may pass out through the corpora 
striata and the efferent nerves in the form of speech or 
motion. This experience is that which takes place during 
the conscious period of wakefulness with most persons, and 
is effected by, and attended with, little conscious effort on 
the part of the individual. 

But this is not all, nor the most important part, of that 
which occurs in this great thought process. At other times 
and during the periods of our occupations, these thoughts 
and ideas do not pass on and discharge themselves ; they 
are seized upon, taken up, examined, looked upon from one 



THE PHYSICAL BASIS OF THOUGHT. 37 

side and then from another, are analyzed, modified, changed, 
and formed into new combinations ; they are approved or 
disapproved by a something superior to any functional 
action in their formation and are finally discharged in quite 
another form from that which they assumed at first ; or they 
may not be discharged from the brain at all. The thought 
process appears in the first instance to be transpiring with 
almost automatic activity, as when one walks without a 
present consciousness of making an effort to take the steps, 
or makes the requisite movements in playing upon an in- 
strument to execute difficult musical compositions. In the 
second state there appears an element which acts upon, 
and to some extent above, the laws of automatic physiolog- 
ical action, and, if it does not change these laws, it certainly 
modifies the result of function over which they preside ; 
and it accomplishes this not through any recognized law 
of which we can have any conception. Laws are invariable 
sequences, and physiological functions which are under the 
control of law, are invariable in their results ; and if the act 
of reasoning is under the control of physical law, and arises 
and proceeds in consequence of that law, then that portion 
of the cortex whose function it is to reason should dis- 
charge its function whenever in a condition to do so. All 
that would be required would be the requisite conditions 
in the way of physiological states of the nerve-cells, and the 
process would continue as long and no longer than these 
conditions should continue, while the results would always 
be uniform. This, however, is the exact opposite of what 
occurs in an ordinary act of reasoning, which begins and 
ends when occurring in a healthy cortex by a something 
which acts upon the functional product, or accumulated 
energy, in the most irregular and inconstant manner, lib- 
erating or restraining the liberation of nerve energy, ac- 



38 LECTURES ON MENTAL DISEASES. 

cording to intention, from time to time, and which proceeds 
with the most variable sequences as to conclusions. This is 
as true in relation to the sensory and intellectual elements of 
the cortex, as of the more specific motor elements ; indeed, 
there can be as little doubt that there exists a motor ele- 
ment, if not a muscular one, in the thought process, as that 
there is one in the execution of acts by any other portion of 
the organism, only it is infinitesimal in character and degree 
in comparison. The motor element in both kinds of func- 
tion differs in degree rather than in quality. 

All this does not imply that in the higher and more com- 
plex mental activities physiological states are of little 
importance. On the contrary, as to conditions, they are a 
prime and antecedent necessity; not only this, the several 
areas and elements of the brain structure, whose function 
is connected with the evolution of thought, require the 
essentials of discipline and training by a self-directing entity 
or energy in the direction of their activities. This is as 
important for the attainment of the highest results as in 
the training of the motor portion of the nervous system in 
the execution of complicated movements of other portions 
of the organism. 

It may be added, in relation to the nature of the thought 
process, even in its nearest approach to automatic activity, 
and when there appears to be no conscious direction given 
to it by the will, that it is as impossible to conjecture how 
impressions radiated to the cortex, or arising in it, should 
cease as movements and appear as thoughts, as it is to 
conceive how they should become sensations of different 
kinds, and it is questionable if they do; they certainly do 
not bear any resemblance to the different mental states, 
such as joy or grief, love or hatred, an imagination or idea, 
which sometimes succeeds them. The most perfect method 



THE PHYSICAL BASIS OF THOUGHT. 39 

of dissecting or analyzing the constituent elements of nerve- 
fibres or cells or protoplasms fails to reveal why, or to enable 
us to conjecture why, any molecular activity arising in the 
nerve should ever ultimate in anything more than molecular 
activity, if it is followed up to its remotest divisibility and 
the most delicate of chemical tests be applied in our efforts. 
No magnifying power of the microscope, no delicacy of 
acting and reacting chemical agents, no comparative analo- 
gies, enable us to span the chasm, however narrow it may 
be, between the final cessation of molecular motion and the 
appearance of sound, taste, thought, and purpose. The 
incompatibility appears to be absolute. 

Now, while it is certainly desirable, in the search after 
scientific truth, to group as large a number of facts as pos- 
sible under one explanation, it is surely not in the interest 
of science, philosophy, or knowledge of any kind to group 
under a single hypothesis those phenomena which have no 
resemblance either in appearance, form, or constituent ele- 
ments. It is, doubtless, easier to conceive of and claim a 
common origin and character for motion and thought, but 
it is not in the interest of science to do this, unless there 
exists at least some external or internal similarity. Diver- 
sity of character indicates diversity of origin. 

" Whenever we see an element produce results such as 
neither its ordinary nature nor the motion in which it is 
for the moment engaged enables us to understand, we 
seek the complementary ground of this effort in the differ- 
ent constitution of a second element, which, acted on by 
that movement, evolves from itself the part in the form of 
the result which we in vain would try to derive from the 
former." (Lotze.) 

This is the statement of the case as between molecular 
activity and thought, and it therefore becomes necessary 



40 LECTURES ON MENTAL DISEASES. 

to introduce another element which is acted upon to 
account for the second of these two wholly unlike classes 
of phenomena. Indeed, the phenomena of the external 
world are apprehended by the mind only in intellectual 
equivalents, and the actual realities thus stand for and 
represent the ideal of the mind. There can be no meaning 
in anything else, and all systems of the higher branches of 
education are founded on this conception. When we read 
a page of any book the physical part of this proceeding 
consists in reflecting and conveying the forms of letters, 
their combinations into words, and the arrangement of 
words into sentences, to the brain. For this purpose there 
has been excited such molecular activity as the various 
forms of letters, words, and sentences were arranged to 
create. But all this is a lesson utterly barren of any 
adequate result. We have not yet got beyond the surface, 
and unless there exists back of these lines, words, sentences, 
and groupings of sentences concepts which cannot be 
reflected by rays of light impinging upon the optic nerve, 
which are apprehended and appropriated, then there can be 
very little in them for us. There must exist in them an 
expression of intelligence, which can only be appreciated 
by an intelligence with similar character. " Mind recog- 
nizes and answers to mind as face to face in a glass." 

Again, take the case of a problem in geometry. Let it 
be required to prove that the squares described on the 
sides of a right-angled triangle are together equal to the 
squares described upon the hypothenuse of that triangle. 
The student may draw the requisite lines and squares ; he 
may read over the statement of the demonstration, and 
even commit it to memory, and he may repeat to another, 
after having constructed the requisite geometric figures and 
lines, the demonstration he has learned, and yet really 



THE PHYSICAL BASIS OF THOUGHT. 4 1 

know little or nothing of the geometric principles upon 
which the demonstration has been based. In other words, 
while the ravs of licdit reflected from the lines in geometric 
figures and the statements of description have excited the 
molecular activity of the nerves and ganglia, and all the 
physical effects have been produced and have been so 
photographed upon the elements of the brain as to be 
remembered and described, yet there may be no apprecia- 
tion of the demonstration of the geometric principle in- 
volved, and the individual will remain as ignorant of it as 
before the occurrence of any molecular activity at all. It 
would appear that only as the thought, which underlies all 
these figures, and the accompanying statements, together 
with axioms and principles, becomes appreciated and ab- 
sorbed by a something possessing a nature akin to thought 
rather than akin to molecular activity, that any geometric 
demonstration has any scientific meaning whatever. Mo- 
lecular activity is and can be but a secondary or subsidiary 
though necessary element, leading toward an appreciation 
of the thought beneath words, sentences, and figures. 
Thought it is which excites thought and "forms character, 
which is the culminating substance of nature," " the great 
reality " which, behind the material world, alone gives it a 
meaning. 

The thought process, therefore, depends upon and is 
accomplished by the action and the reaction of the nerve- 
cells of the cortex, and another element, call it " force," 
"spirit," " mind," or whatever else you please, which pervades 
it. This second element, the personality, acts and is acted 
upon, and, we may suppose, pervades the cortex as electri- 
city pervades the elements of a portion of iron. 

The term mind, as used above, may be regarded as equiv- 
alent to either of the terms, ego, soul, or personality. These 



42 LECTURES ON MENTAL DISEASES. 

terms, however, are made use of by writers as designations 
of different entities or phenomena. Some use them as sig- 
nifying a spiritual entity, in its nature akin to the creative 
or formative principle of the universe. Though linked with 
a physical nature and dependent upon it for its manifestation 
of person, yet it is of a nature essentially different. As the 
universal creative Being evolves, acts upon, and directs the 
laws which pertain to nature, so, in like manner, though in 
an infinitesimal degree, does the mind, or ego, in man, dis- 
cover and act upon and mould the laws with which he is 
environed to subserve his own plans and purposes. Some 
such meaning has attached to the terms from the beginning 
of the history of philosophy. It is, however, a hypothesis 
which by its nature can no more be mathematically demon- 
strated than can personal identity. One may assume it to be 
true and, from the correspondence of phenomena connected 
with it, argue for or against the probability of its truth, 
while the conclusions arrived at will vary very much accord- 
ing to the bias of mind with which the question is examined. 
This is one of the problems in which the personal equation 
will form an element of great weight in determining the 
issue. 

Other authors have used the term ego as equivalent to 
the product, or sum total, of the stream of impressions which 
never cease to flow through the sensorial avenues to the 
brain from the date of birth to the hour of death. Accord- 
ing to this view every individual ego is a variable and an ever 
varying quantity. It is one ego to-day, but was a largely 
different one last year, and will possibly be a still more 
widely different one next year. Nay, it varies from day to 
day and from hour to hour; is constantly added to or sub- 
tracted from, according to experiences and the obliteration 
of them from memory. An imperfectly functionating liver 



THE PHYSICAL BASIS OF THOUGHT. 43 

changes the ego of to-day, while a neuralgic twinge of the 
fifth pair of nerves will make another man of him to-morrow. 

Personal identity is simply the sum of those memories 
which at any one time is in the field of consciousness. This 
is, therefore, also an ever shifting and uncertain element, 
and never, perhaps, in a lifetime exactly twice the same. 

It may be remarked concerning this view that the modus 
operandi of the transformation of an impression, or ■ any 
number of them, upon the end organs of sense, after passing 
to the cortex into an entity, or a personality, which at once 
becomes endowed with the capacity to examine, compare, 
approve, or disapprove of the very impressions which con- 
stitute itself, cannot readily be comprehended. It certainly 
cannot be regarded as capable of any scientific demonstra- 
tion. An effort to make one would be much like an endeavor 
to lift oneself by one's boot-straps. Indeed, all questions re- 
lating to the intrinsic nature or source of mind, or the ego, 
are comparatively profitless for the physician. That there 
exists such an entity which is capable of acting upon the 
phenomena of nature through the nervous system, and also 
can be acted upon through the same avenues, is sufficient, 
and this will be assumed in the following lectures.* 

* Dr. O. Everts writes as follows in reference to the view of the ego above 
referred to. It " implies a personalization of phenomena and an ascription 
to ideal objects or persons so instituted, of attributes denied to all known 
material objects or beings, after the manner of the ignorant of all ages and all 
races.'' 

In reference to the spiritualistic view of the ego, or mind, he says : " Ad- 
mitting the existence of individuals, spiritual beings, is it not rational to infer 
that they are specializations from spiritual matter of individual spirits, subject 
to evolutions and dissolutions, corresponding to the changes that effect material 
specializations ? Must we not recognize such beings, if at all, as objective, 
having form and, necessarily, substance? Hence specialized from one eternally 
existing common substance, hence subject to dissolutions ? Were it not so, 



44 LECTURES ON MENTAL DISEASES. 

Permit me to recall the several specialized organs or 
portions of the nervous system which have been referred 
to. They are the cortex, the basal ganglia, and the two 
great systems of afferent and efferent nerves. These are 
the physical instruments, intricate and most complex in 
their constitution, through which impressions reach the 
personality, and by means of which both they and the 
memories of past experiences are moulded into opinions 
and purposes, and finally projected from the brain in the 
form of speech or motion. Such being the anatomical and 
physiological relations of the brain to the thought process, 
it follows that any sufficient derangement or disorder of its 
normal condition or arrangement, and of its physiological 
activities, from whatever cause it may arise, would result 
in change of thought, feeling, and movements, as surely as 
a derangement or injury of the nerves of the extremities or 
the fingers will cause imperfect execution or total paralysis 
of their movements. 

It is not to be inferred from the above statement that 
such changes can be demonstrated by observation with 
the microscope or any other instrument, in all or in 
a large per cent, of all cases. They, however, can be in 
certain forms of insanity, and especially in cases which 
have existed for a lengthened period of time. This could 
be inferred from a consideration of the changes and modi- 
fications of mental activities which occur from slight causes 
and which continue for short periods. The action of the 

were matter capable of specializations not subject to further changes and an 
inevitable dissolution of individual forms, the limits of specialization having 
been once reached, all activity would cease, all nature end, and the world, the 
universe, become a vast assemblage of motionless, purposeless individuals, im- 
mortal, but incapable of any of the functions or enjoyments of living beings." — 
American Journal of Insanity, October, 1886. 



THE PHYSICAL BASIS OF THOUGHT. 45 

cortex is so intimately connected with and dependent upon 
the general circulation, that it is constantly modified by 
changes in it, and yet these changes leave no permanent 
trace of having existed. We certainly have no chemistry 
or reagents which can detect the difference in the action of 
the cortex in the formation of a delusion, as distinguished 
from that of a correct conclusion. The same anatomical 
elements are doubtless in operation in the process of form- 
ing both, but the difference arises in the ultimate synthesis 
of impressions, some producing too much and others too 
little influence upon the personality. 

In observing the modifications of mental activities in 
cases of acute mania, for instance, we are able to trace the 
normal mental trend of the individual in what he says and 
does. Attention, perception, recollection of past events, 
expression in words and act, have a correspondence in char- 
acter with the previous history in these respects, only they 
have become quickened and exaggerated in a greater or 
less degree. This is at least primarily due to an increase 
or diminution of function in some one part, in its relation 
to other parts of the brain, and may continue for consider- 
able periods of time without such disturbance in the texture 
of the brain as to become registered. The same must be 
true as to the conditions attending the states of melancholia. 

Again, it does not follow that in all cases in which some 
portions of the cortex and ganglia are found to have been 
in a pathological state, therefore the mind must have been 
correspondingly deranged. They may have been produced 
by habits of living or by confinement, and yet have not 
given evidence of existence in life by modifications in 
mental activity sufficiently pronounced to attract attention. 
Your attention will hereafter be directed to the forms of 
disease in which pathological changes have been observed. 



46 LECTURES ON MENTAL DISEASES. 

Numerous causes may operate to produce derangements 
in functional activity. It may arise from an anaemic or 
congested state ; by a sudden change from one state to 
another ; by failure in assimilative power ; by a long- 
continued over-product of functional activity; or, on the 
other hand, by a lack of it ; by certain substances which 
have a special affinity of action and which reach the hemi- 
spheres of the brain through the circulation — such as 
chloroform, ether, bichloride of ethyl, and other so-called 
anaesthetics, which cause a paralysis or suspension of con- 
sciousness. The nerve-tube is also acted upon by its 
environment, by accidents or force, and by special sub- 
stances, among which may be mentioned nux vomica, 
electricity, strychnine, etc. 

Again, if the circulation of the brain be suddenly im- 
peded by compression of its vessels or from deficiency of 
heart action or failure of nerve force, vertigo or syncope 
will ensue and consciousness cease until the circulation of 
the organ is restored. Slight changes in the circulation 
produce correspondingly slight mental changes. 

Of the nature of nerve energy we know very little. We 
are unable to observe or examine it ; we cannot separate it 
from the nervous system and experiment with it; we can- 
not put it to many tests, nor can we understand from actual 
observation what takes place when the nerve transmits im- 
pressions. We are able, however, to ascertain the data of 
some phenomena connected with and evolved from its 
action. We can measure its capacity of endurance or 
resistance, and how this may become affected by environ- 
ments ; by foods and drinks of diverse kinds ; by the 
seasons of the year and the hour of the day ; by different 
mental states, such as hope, joy, anticipation ; by grief, dis- 
appointment, reverses of fortune, etc. We can measure 



THE PHYSICAL BASIS OF THOUGHT. 47 

the length of time required in different persons for the 
nervous system to re-energize after exhaustion, the period 
required for sensory and intellectual acts to occur, and some 
other of the mental phenomena connected with it. We know 
that its action differs from that of electricity or other 
known elements ; its movement is slower than that of light 
or electricity, it being only some thirty-two or thirty-four 
metres per second, while that of electricity is many thousands 
of metres per second. 

Again, nerve force moves toward the brain at about the 
rate of thirty-two or thirty-four metres per second, and 
from the brain at only about twenty-seven metres per 
second. 

An act of perception varies in point of time, to some 
extent, with different persons, but averages about one-tenth 
of one second. Such investigations, and others of allied 
character which pertain to what is termed the physiology 
of psychology, are of the highest importance and may be 
regarded as the most promising means of preparing the 
way for the rational treatment of mental disorders. 

All mental manifestation, whether moral, intellectual, or 
emotional, will depend largely upon the condition and 
functional activity, whether it be normal and healthy or 
otherwise, existing in those portions of the nervous system 
described above. The molecular activities which are con- 
stantly taking place during the processes of thought, speech, 
and action must be almost infinite in number, and when 
deranged by the invasion of disease cause changes in per- 
ceptions, thought, and corresponding action. Such derange- 
ments of functional activity must be regarded as a basal 
element of insanity. 



IvKCTURK II. 



ELEMENTS OF INSANITY. 



HALLUCINATIONS— ILLUSIONS. 

Definition — ^Etiology — Difference in Hallucinations of the sane and insane — 
Modifications in the Circulation — Congestions — Toxic Agents— Inflamma- 
tions — Imperfect Nutrition — Hallucinations of Hearing — Illustrations — 
Hallucinations of Sight — Frequency of — Hallucinations of Smell — Hallu- 
cinations of Taste — General Sensation — The Sexual Organs — Import of 
Hallucinations — May Lead to Homicide or Suicide — Often present in 
Larvated Epilepsy — Intensity of Hallucinations — Frequency of — Table of 
Cases — Treatment. 

Illusions — Definition — Illusions of Sight — Illusions of Visceral Sensibility — 
Very numerous — May depend upon the existence of morbid growths — 
Present in Delusional Insanity — General Paresis and Melancholia. 

Hallucinations are false perceptions — perceptions of 
objects which have no existence except in the brain of the 
person perceiving — and consist in interpreting thoughts as 
real sensations. In real perceptions the cerebral cortex is ex- 
cited by irritations transmitted to it through the peripheral 
nerves from the external world, while in hallucinations its 
action is excited by the presence of morbid conditions in 
certain portions of it. 

" Hallucinations are subjective sensorial images which 
are, however, projected outward and thereby become appar- 
ently objects and realities." (Griesinger.) 

It is a hallucination when I perceive a person standing by 

4 8 



HALLUCINATIONS. 49 

my side, or hear a voice in the next room, and neither the 
person nor the voice exists. 

They consist in the revival of past experiences in those 
portions of the grey substance of the brain which are con- 
nected by nerve-fibres with the special organs of sense. 

The train of thought, however, being once initiated, tends 
to become modified and changed by the introduction of 
other elements of past experience, and in the process of 
reflection new pictures or sounds will be formed, which will 
be presented to the mind as objects or realities, but which 
have never previously existed in the mental history of the 
individual. 

They are caused by a morbid irritation, or excitement of 

1st. Some portions of the afferent nerves within the 
brain, or 

2d. Of some portions of the central ganglia, or 

3d. Of limited areas of the cortex. 

As undulations of light and the vibrations of the atmos- 
phere affect the peripheral expansions of nerves and cause 
excitations which are transmitted to the central ganglia, and 
are there converted into true sensations, so in like manner 
do impressions which arise from the operations of morbid 
processes in the brain itself re-create sensations the memory 
of which has been stored up from past experiences. 

Persons hear, see, touch, and taste all varieties of objects 
which have no actual reality, and yet the derangement may 
not exist primarily in the psychical centres, but in the sen- 
sorial ganglia, or the afferent nerves. There may be neither 
excitement, incoherence, depression, or dementia. The 
mind perceives what appears to be an actual sensation 
caused by an external reality, but which really comes from 
a subjective cause, that is, irritations of the sensorial centres 
from within. The difference between hallucinations in sane 
5 • 



50 LECTURES ON MENTAL DISEASES. 

and insane minds is that in the former state the mind is 
able to recognize that the cause is acting from within, and 
that the sensation is not real, and is governed accordingly. 
The hallucination does not lead on to the formation of de- 
lusions or to conduct inconsistent with the mental character 
of the individual, but when the psychical centres are 'also 
disordered, the personality becomes unable to recognize 
the error and correct it. It may not always be possible 
to determine the dividing line in the onset of delirium. 
Patients may be aware of the hallucination at first, and 
realize that it is one, and yet as the disorder progresses 
they lose the power of correcting their sensations and be- 
lieve the objective reality of their hallucination. In such 
cases it is reasonable to suppose that the disordered process 
giving rise to the hallucination may originate in the 
cortex, rather than in the basal ganglia or sensory nerves. 

These morbid changes may arise from various causes, 
such as — 

ist. Change in blood supply of the brain. 

2d. From toxic substances introduced to the brain 
through the circulation. (Stramonium, Hashish, etc.) 

3d. From congestion and inflammation affecting the 
membranes and vessels of the brain. 

4th. From derangements of the nutritive processes 
of the brain by long-continued fastings, mental over- 
exertions, mental shocks, unfortunate experiences, 
organic growths, slight hemorrhages, local hyperses- 
thesias, etc. 

They may exist even in cases in which the peripheral 
terminations of the special organ affected have been de- 
stroyed by disease. There is a patient in the Retreat at the 
time of this writing who lost her hearing in consequence of 
an attack of scarlet fever when a small child. She has 



HALLUCINATIONS. 5 I 

periods of being much excited, feeble, emaciated, and sleep- 
ing but little. She will then take no food voluntarily, and 
indicates (she has been highly educated as a deaf mute) 
that she thinks it has been poisoned. At such times she is 
almost constantly engaged in endeavoring to reply to 
voices which she is apparently listening to by placing her 
head near the door or the wall of her room, whence they 
seem to come. 

Any one of all the organs of sensation may become hal- 
lucinated, and it is not uncommon to have both sight and 
hearing disordered at the same time. Several cases have 
been recorded in which all the senses were affected at the 
same time. 

In the order of frequency, hallucinations of hearing 
stand first, comprising more than one-half of all cases which 
have any form of hallucinations. These more often consist 
in the sound of voices, though other sounds are often heard, 
such as the singing of birds or the falling of water and the 
ringing of bells. Single words or the name of the indi- 
vidual himself may be heard, as of one calling, but generally 
sentences are formed and directions are issued. The person 
hears voices commanding him to do this, and not to do 
that ; to pray or not to pray ; to commit suicide or kill his 
attendants, not to take food or drink, etc. The voices may 
seem to come from within the brain or from persons who 
are in other portions of the house, in rooms above or 
below ; they may be bilateral or unilateral. They are more 
frequent in the erect than in the recumbent position. 

The subject matter to which these hallucinations may refer 
will depend, to some extent at least, upon the character of 
the memories of sounds which have been heard and appre- 
ciated by the individual. Persons who have " no ear for 
music," and have had but little appreciation or interest in 



52 LECTURES ON MENTAL DISEASES. 

singing when in health, will rarely have hallucinations 
relating to it when disordered. Hence, the sounds of the 
voices of persons or animals are most frequently present. 

Hallucinations of hearing may be present in melan- 
cholia, mania, and delusional insanity. They indicate 
serious and profound disturbances of the brain, and often 
render patients dangerous. 

The following case will illustrate, by the statement which 
the patient sent me in a printed form (after consultation 
with me in reference to his " trouble in the head," as he 
called it, which he said had existed for several years), how 
entirely hallucinations of hearing and sight at times domi- 
nate the whole course of mental activities : — 

" I hereby appeal to his Excellency to protect me in the 
exercise of those personal rights which are specified in the 
Declaration of Independence, guaranteed to me by the 
Constitution of the State, and clearly understood by all 
intelligent persons as the common law of this and every 
civilized nation — I mean the right to move, live, breathe, to 
lie down or sit up, to eat, drink, sleep, or perform any of 
the necessary functions of life ; to walk the streets, ride in 
railway cars, reside in hotels or private houses, frequent 
places of public resort, transact any business ; in short, to 
do any and all those things which are implied in the 
Declaration as the ' inalienable rights of man,' without being 
watched, inspected, scrutinized, spied, pursued, dogged, beset 
by prurient, malicious eavesdroppers and retailers of gossip ; 
bantered, badgered, browbeat, taunted, talked at, talked to, 
or talked about in an undertone by passengers in the street ; 
menaced by word or look ; ridiculed, insulted, imposed upon 
by any human person of high or low degree, whether 
stranger or relative, millionaire or hoodlum, society women 
of the first class or of any class. All these indignities 



HALLUCINATIONS. 53 

enumerated I have experienced during the past year, from 
all classes and conditions of mankind in this State. Con- 
temptible, hypocritical, prying, prurient, malicious, revenge- 
ful eavesdroppers, .gossips, and clowns have watched me by 
day and night, and prevented me from sleep by the inces- 
sant babble of their venomous tongues. Men and women, 
callow youths, club men, sporting men, their wives and 
daughters ; millionaire merchants and bankers ; directors 
and trustees of banks, railroads, mill corporations, charitable 
institutions, and hospitals ; shop-women, washer-women, 
women of the first circles and lowest circles and of all cir- 
cles, have marched or driven in procession up and down the 
streets of Boston and Dedham for the past year, armed with 
the shibboleth of the party or persons whose cause they 
have espoused. I have observed this procession closely 
for a whole year, and carefully noted the epithets and 
phrases they have hurled at me : ' perfect fool ; ' ' deter- 
mined to be an idiot ; ' ' nothing but an idiot ; ' ' lunatic 
and a fool ; ' ' turned out an old fool ; ' 'let up on this 
man ; ' Met up on that man ; ' Met up on this woman ; ' 
'let up on that woman,' and innumerable other insults." 

Hallucinations of sight stand next in order of frequency 
to those of hearing, and in very acute cases are even more 
common. They may occur at night as well as during the 
day, with eyes closed, and also in those who are blind ; 
they may relate to objects or persons. In cases of acute 
excitement with increase of temperature, there may be mere 
flashes of light or colors, or the seeming perception of 
birds, reptiles, vermin, etc. In chronic cases the halluci- 
nations may become systematized, and the patient perceive 
the same object day after day. 

B. D. A., chronic melancholia, insisted that he could see 
the figure of a bird on the back of his head every day 



54 LECTURES ON MENTAL DISEASES. 

during several months, and afterward, during nearly a 
whole year, that he could see the figure of the chaplain 
of the Retreat clearly drawn on a portion of my face when- 
ever I entered the room. 

Patients have sometimes visions of the supernatural — of 
angels or spirits of departed friends, and at the same 
time hear expressions of happiness or rejoicing, or those of 
suffering and misery. In alcoholic insanity they are nearly 
always of a very unpleasant character. 

Hallucinations of smell are present in but few cases of 
insanity ; they may exist in acute or chronic cases, but are 
more common in acute. They are generally of an unpleas- 
ant character, and relate to smells of dead bodies, poisonous 
exhalations, offensive odors of other patients, or noxious 
gases which are thought to exude through the floors or 
walls of the rooms which they occupy. 

E. W., a case of primary delusional insanity, thought his 
brother filled his room with gas at night, and consequently 
he left it for another, and then another, until he finally left 
the house and slept in a shed, and persisted in so doing 
until he froze some portions of his feet. He was then 
brought to the Retreat. 

Hallucinations of Taste. — It is sometimes difficult to 
determine whether an abnormal taste complained of is de- 
pendent upon the deranged secretions of the stomach, a 
coated tongue, or upon a hallucination. Unpleasant tastes 
are common enough from the first named causes, and the 
supposed taste may be more nearly an illusion than a hal- 
lucination, and depend upon a transformation by the de- 
ranged mind of one kind of taste into another. Without 
doubt, however, true hallucinations of taste exist in some 
cases ; they generally are of an unpleasant nature, such as 
decaying animal substances, rotten eggs, blood, etc. They 



HALLUCINATIONS. 55 

sometimes form the basis of the delusion that the food 
which is used has been poisoned. 

Hallucinations of general sensation may occur in 
any portion of the system, external or internal. The 
skin, the viscera, and the genital organs are more fre- 
quently the parts affected. It is even more difficult to diag- 
nose as between hallucinations and illusions of the viscera 
than of taste. Sensations arising through the peristaltic 
action of the bowels are of frequent occurrence at all times, 
but in a state of health are so weak as to attract little atten- 
tion, though they may be easily misinterpreted by a dis- 
eased mind. There may exist a condition of hyperesthesia, or 
organic growths, the presence of which cannot be detected, 
but which render all such movements acutely painful. When 
the skin is the seat of the hallucination, it is of a painful 
nature. 

Mrs. M. complains that spirits are pouring liquid lead 
over her head, and that it runs down her spine ; that her 
hair and scalp are burned off, leaving it a bleeding, horrible 
sight. 

Mr. E. complains that there is a child in his chest, and 
that it is an outrage that it is not removed at once. 

Mr. C. says that electrical influences affect his whole 
spinal cord, shooting up and down as if needles were being 
inserted, and that at times they extend to his finger ends. 
At other times, and whenever the night-watch passes the 
door of his room, he is conscious that some influence acts 
upon his scalp which draws it more tightly over the bones 
of his head ; that at other times it screws his brain up into 
a corner of the cranium, or twists one of his eyes from its 
axis. 

Hallucinations of the sexual organs may form a special 
class by themselves, and are often present in some forms of 



56 LECTURES ON MENTAL DISEASES. 

insanity leading to masturbation and inordinate sexual 
desire. 

Women complain that men enter their rooms at night and 
abuse them ; they imagine that they are pregnant, or that 
they have intercourse with angels, etc. The sensations with 
men are often of a voluptuous character, and they imagine 
that beautiful women visit their rooms at night. In other 
cases a sensorial derangement of the sexual centres of the 
brain leads to the belief that the patient has been castrated ; 
in other cases to suspicions of marital fidelity, and consequent 
homicides. They also sometimes form the basis of horrible 
delusions and impulses which lead to self-mutilation and 
the removal of the sexual organs. 

The Import of Hallucinations. — They do not invariably 
indicate insanity; they sometimes exist in sane persons, 
especially during sleep, or when only partially awake. 
Doubtless hallucinations of sight are more frequent during 
dreams than those of hearing, and also become recorded as 
experiences more perfectly. Dreams sometimes occur in 
which both sight and hearing become hallucinated, as when 
one sees the picture of his own face while it is being photo- 
graphed ; he sees its characteristics of likeness and unlike- 
ness to himself, especially the unlikeness, which doubtless 
arises from the imperfectness of the representation on the 
brain centres. He may also hear his own remarks offered 
in commendation, or criticism of it, and be able to recall 
the whole dream with more or less distinctness immediately 
after he awakes, but the impression usually remains only 
for a short time. 

Any of the special organs of sense may be hallucinated 
while one is dreaming, and the person is often awakened in 
consequence of the vividness of the impressions which are 
transmitted to the sensorium. Indeed, the physiological 



HALLUCINATIONS. 57 

process of dreaming may be regarded as a hallucination of 
the psychical centres of the brain. 

Persons of the highest intelligence have experienced hal- 
lucinations for years, and without impairment of mental 
integrity. This is not unfrequently the case in females after 
the great climacteric in consequence of the change in the 
circulation of the brain. It is also true sometimes in elderly 
persons in consequence of pathological changes in the blood- 
vessels which are in the vicinity of the auditory nerve. They 
complain of sounds as of the beating of drums, the falling 
of water, the rumbling of carriages, or the shout of a multi- 
tude of people, etc., etc. 

A person once complained to me that he was annoyed 
with the sight of a man dancing among the trees of the 
lawn whenever he looked from his windows in the morning;. 
He realized that such a thing was quite impossible, and 
recognized it as a hallucination. An improvement in his 
general health caused the hallucination to cease. 

Jeanne d'Arc presents one of the most remarkable cases 
of hallucination of hearing on record. Beginning at the 
pubescent period, and while she was tending her father's 
sheep on the hills of Domremy, they were interpreted, in 
accordance with the intelligence of the times in which she 
lived, as the voices of angels. They continued with little 
remission through all the eventful and terrible scenes of 
war and carnage through which she eventually passed. 
They brought solace and comfort, and sustained her in 
the final experience to which she was consigned by the 
barbarous usages of the age. There certainly exists no 
evidence that they extended to the psychical centres or 
developed insane delusions. 

Cases are reported in which hallucinations of sight have 
existed during many years with mental integrity apparently 



58 LECTURES ON MENTAL DISEASES. 

unimpaired, and in which, after death, disease of the optic 
nerve has been found. Such cases are, however, not fre- 
quent, and hallucinations proceed from the existence of 
morbid processes in the central ganglia which extend to 
or influence other portions of the brain and cause insanity. 

The degree of their importance may be inferred in a 
general way from the character of the disease with which 
they are connected. In cases of acute insanity attended with 
excitement, and especially in alcoholic insanity, they are not 
of serious import and almost invariably pass away when 
convalescence becomes established. Hallucinations of hear- 
ing in primary delusional insanity, and melancholia attended 
with insistent ideas, delusions of persecutions and depres- 
sive emotional states, are of serious import, and indicate 
the importance of seclusion and treatment. They become 
the cause of many homicides and suicides, and it is quite 
impossible to prophesy what may be the conduct of per- 
sons at large who believe themselves under the influence 
and direction of voices which are all the while with them 
and directing their conduct. 

Yet in these forms of insanity the danger will depend 
much upon the nature of the delusions which are present. 
When these are of an exalted character, and the person 
imagines that he is a person of great importance, and holds 
offices of large trust, or that he is the trusted agent of others 
in high station, there will be little or no danger. Cases are, 
however, reported in which homicides have resulted from 
resentment from wamt of respect for the patient's imagined 
dignity. If, on the other hand, there exist delusions of per- 
secution, and the patient thinks he is deprived of his just 
rights, if he is taciturn and broods over his imaginary 
wrongs, and especially if he has delusions of persecution, 
with loss of sleep, or if he has epilepsy in any form, then 



HALLUCINATIONS. 59 

too great caution cannot be exercised in reference to proper 
care and seclusion. 

Hallucinations of sight and hearing are frequent in 
epilepsy. This is the case especially in larvated epilepsy, 
and when the convulsion does not become fully developed. 
Such patients often see flames of fire, luminous balls, or 
brilliant pictures of places, houses, persons, or animals 
when they are approaching an attack, or after the congested 
and convulsive stage has passed and consciousness has be- 
come partially restored ; or they may hear the sound of 
voices which seem to come from persons seen and which 
issue commands to do or not to do certain things. Hallu- 
cinations of general sensation in the form of heat or cold 
are often present and constitute the primary element of the 
convulsive stage. They may be of an agreeable character 
or cause distressing emotions in the subject. 

Hallucinations of sight are often present in congestions 
and inflammations of the membranes of the brain, and in 
typhus and typhoid fevers when of a serious character. 

F. H., a student, was prostrated by a severe attack of 
typhus fever, and on the third or fourth day became deliri- 
ous. During the ten or twelve subsequent days he was 
nearly all the while, when not sleeping, greatly troubled 
and affrighted by spectral hallucinations of a horrible 
character, which seemed to be ever present before his eyes. 
In this case none of the other organs of sense were hal- 
lucinated. 

Hallucinations are sometimes present during periods in 
intermittent fevers. They are also common in patients who 
remain much in solitude, absorbed in their own meditations 
especially if they refuse food. 

The Intensity of Hallucinations will differ very largely 
in the different genera of insanity and in different cases of 



6o LECTURES ON MENTAL DISEASES. 

the same genus. In some cases they become extremely 
vivid, and the impressions upon the psychical centres con- 
tinue for days so distinct as to be recalled and explained, 
while in other cases they appear to be faint, confused, and 
soon forgotten. It is, however, characteristic of hallucina- 
tions in the insane that they do not continue more than a 
few minutes, or a very short period, without interruption, 
and that their registrations are soon effaced. In hallucina- 
tions of hearing the voice-sounds cover only short sentences 
with frequent interruptions and with changes in character 
and subject matter. 

Esquirol estimates that hallucinations are present in 25 
per cent, of all cases of insanity. This is not a higher 
proportion than would accord with my experience in acute 
cases. 

The table, page 61, comprising 307 cases, arranged by 
Dr. Edward B. Lane to illustrate the frequency of hallu- 
cinations of the different senses in several forms of insanity, 
will confirm in a general way the accuracy of the preced- 
ing text.* 

Treatment. — The physiological basis of hallucinations is 
such in most cases that they cannot be controlled or much 
modified by the use of medicines, except indirectly. When 
they depend upon an an ansemic condition of nerve-tissue 
they may be relieved by the use of such medicines as will 
improve this condition. They may also be relieved when 
due to a congested state of the vessels ; in some few cases 
by the use of bromides, digitalis, and belladonna. Some 
cases in my experience have been relieved by the subcuta- 
neous use of the hydrobromate of hyoscine. This latter 



*" Hallucinations in the Insane," Boston Medical and Surgical Journal, 
Vol. cxxv, No. 1 1 . 



HALLUCINATIONS. 



6l 



remedy, however, has proved to be even of temporary ser- 
vice in only a limited number of cases, and it has not yet 
been determined as to what class of cases it may afford any 
relief. 

HALLUCINATIONS. 





H 

z 

o 

►J 

< 

a 

2 

s 

< 

H 

tn 

38 
32 
15 

9 

3 
4 
'4 
2 

" 6 
1 

114 


z 



< 

H 

X 



5 

2 
1 

4 
5 



19 


12 

< 

H 

K 
O 
►J 
J 
W 

S 

O! 

2 


H 

X 
O 

c/5 



z 

< 

z 

2 

18 
9 
3 
3 
2 

2 

2 
2 

1 
2 
2 

47 


■j 
w 
S 
m 

Q 
Z 
< 

H 

K 

w 

0" 
z 
5 
< 

H 

a 

5 

4 



""" 

*i 
10 


s 

u 

D 
O 

H 
a 
z 

< 

z 
S 
< 
w 
W 

2 
2 


s 

u 

O 
H 
a 
z 
< 

« 
2 

c/5 

0" 
z 

< 
w 

I 

I 


►4 
J 
H 
S 

a 
z 

H 
X 
O 
C/2 








M 
Z 

O 

5 
20 

19 

7 



-5 

5 
16 

""3 

2 
10 

7 
6 

in 


< 

H 
O 
r-i 

67 

55 
38 
34 
10 

6 

8 

4 
6 
29 
3 
4 

2 

10 

7 
6 

3°7 


Paranoia, 

Acute melancholia, . . 
" mania, 

General paralysis, . . . 

Post- paralytic insanity, . 
; Other organic brain dis- 
eases, 

Epileptic insanity, . . . 
i Insanity of pubescence, . 

Katatonia, 

Hysterical insanity, . . 

Senile insanity, .... 

Alcoholic insanity, . . 

Recurrent mania, . . . 

Folie du Doute, . . . 

Simple mania, .... 
" melancholia, . . 

Folie circulaire, .... 

Senile dementia, . . . 



* And touch. 



The course of treatment should be indicated by the con- 
ditions and peculiar indications present in each case, and 



62 LECTURES ON MENTAL DISEASES. 

generally without reference to the kind of hallucinations 
which may exist. It should be borne in mind that they 
are mere symptoms of morbid processes, and that as 
these become modified or improved the hallucinations will 
disappear. 

The moral management of cases affected with hallu- 
cinations should have especial relation to them, and, indeed, 
may become one of the most effectual means of lessening 
their intensity. 



ILLUSIONS. 

Illusions consist in false interpretations of external ob- 
jects. The peripheral terminations of nerves receive and 
transmit the impressions, but when conveyed to the brain 
centres they do not become accurately intellectualized. 
The derangement exists in the process of changing the 
transmitted physical impressions into psychical ones, hence 
the mental concept is imperfect or incorrect, and the illusion 
consists in an error of the judgment in interpreting the 
significance of these impressions when they reach the sen- 
sorial centres. In hallucinations the irritation and conse- 
quent mental concept are entirely subjective, but in illusions 
the irritations and impressions are wholly from without. 
Such a result might ensue from either a partial anaesthetic 
or hyperaesthetic condition of the psycho-physical centres 
of the brain; the sensations would then be diminished, 
heightened, or changed, resulting in imperfect and, conse- 
quently, deceptive impressions on the mind. 

It is an illusion when one sees a circle of fire from the 
rapid revolutions of a burning stick, or hears the voices of 
friends from the moaning of the wind, or in the conversa- 
tion of strangers. 



ILLUSIONS. 63 

Illusions may often relate to what may be occupying 
the mind of the person, or what one is very anxious 
about. 

A patient is exceedingly desirous of seeing her husband 
or child, and when a stranger passes the door or residence, 
or enters the hall, is sure he is the one so long expected ; or 
she hears the voices of persons in conversation in the next 
room, and is confident that one of the voices is that of her 
husband or the child she is so constantly thinking about. 
Again, they may arise from the revival of impressions and 
memory of persons received long ago. When Mrs. P. meets 
Mrs. S. she at once associates her with some person whom 
she has known years before; a possible likeness becomes 
an identity in the deranged brain centres. 

Illusions of Sight are more frequent among the insane 
than those of the other organs of sense. 

Mrs. B. rarely sees a person pass by the windows of her 
room that she does not address him as her husband or 
some one of her three sons, all of whom she is confident I 
have forbidden seeing her and confined in the basement of 
the Retreat. In this case the illusion has its basis in the 
delusion that her family, who never come to see her, are 
prevented doing so by being confined. This delusion has 
increased until it extends through and embraces the whole 
mental horizon, and pervades it more largely than anything 
else during her waking hours. Hence, the mind is always 
in an expectant state, so that persons, like or unlike those 
she thinks of, are mistaken for them. 

Illusions of Hearing and Smell are of much less fre- 
quent occurrence than hallucinations of those organs. 

Illusions of Visceral Sensibility are very numerous, 
and are often met with among the insane. They are nearly 
always of an unpleasant, singular, or painful character, 



64 LECTURES ON MENTAL DISEASES. 

and may exist in the stomach, the alimentary canal, or the 
uterus. 

O. S. believed that he had some kind of a snake in his 
side, which had been introduced into his stomach by drink- 
ing water from a spring on some former occasion. He 
could feel its movements in his right side, as if it was coil- 
ing itself about some portion of an organ within the body. 
After his death an examination disclosed a cirrhosed liver. 

Mrs. M. has hypertrophy of the heart, attended with ir- 
regularity of action, and she is confident that the spirits of 
some of her departed enemies are engaged in turning the 
air-passages of her lungs about in such a manner that they 
extend from side to side instead of up and down. At other 
times they insert poison into her stomach, and she becomes 
so nauseated that she can take no food and is ready to 
vomit. At another time her lungs are filled with the parti- 
cles of some poisonous substance, which she is confident 
will soon destroy her. 

Derangements and morbid growths of the uterus often 
give rise to illusions of general sensibility, and women im- 
agine that they are pregnant. Mrs. S., who is passing through 
the climacteric period, came to consult me on two occasions 
as to her confinement. She is very confident that such 
sensations as she experiences about the pelvis could come 
from no other cause than pregnancy. 

Illusions may occur among the sane as well as insane, 
but with this difference. When persons in the normal con- 
dition of the psychical centres experience optical or sensa- 
tional illusions, such as luminous balls passing before the 
eyes while they are closed, from compression of the cornea ; 
or experience a misinterpreted sensation of heat or cold, 
they are able immediately to recognize the mistake and 
correct the illusion. 



ILLUSIONS. 65 

On the other hand, when illusions occur in the insane, 
they are unable to correct them in consequence of a de- 
rangement affecting the psychical centres of the brain. 

Illusions of sight, hearing, and general sensation are fre- 
quently present in delusional insanity, melancholia, and 
general paresis. Wrong, imperfect, or exaggerated inter- 
pretations are given to experiences which have but a slight 
foundation in fact, and give rise to delusions. The ticking 
of the clock on the mantel becomes converted into the 
voice of one speaking, to whom replies become necessary ; 
the pain incident to an ulcerated stomach becomes the 
evidence of the presence there of a snake which has been 
swallowed on some former occasion. 

Illusions of the different senses are also often present in 
the acute forms of alcoholic insanity, and in forms of dis- 
ease other than insanity. They are generally of much less 
importance than hallucinations. 



LECTURE III. 



IMPERATIVE CONCEPTS— INSISTENT IDEAS. 

Contents : — Concepts — Definition of — ^Etiology — Mode of Origin — Forms of 
Disease — Progress and Course — Illustrations — Character of Concepts — 
Significance of — Insistent Ideas — Formation and Progress — Character- 
istics — A Case of Long Standing — The Emotion of Fear— Fear of Places — 
Of Contamination — Of Improper Conduct, etc. — The Subjects about 
which they Revolve very Numerous — A Case — Characteristics as Described 
by Krafft-Ebing — Treatment. 

Concepts, as used in the following pages, may be re- 
garded as the simplest forms of mental action, after those 
of sensation and perception. They are isolated thoughts 
relating to things or subjects. They are limited, and con- 
stitute the elements of thought processes which enter into 
judging, reasoning, and the formation of designs, purposes, 
etc.* They become imperative when they occupy the 
mind for the time being and dominate its course of action. 

Etiology. — Imperative concepts arise from the operation 
of irritations, either centric or reflex, acting upon brain 
centres of thought which are in an abnormal physiological 

* This is a more limited signification of the term concept than is in common 
use, where it is made equivalent to the term notion, which embraces not only 
the first impression of any subject or thing, but also the qualities or charac- 
teristics which pertain to it. I have, however, ventured to use the word con- 
cept rather in its etymological sense, as signifying the initiatory element of the 
thought process pertaining to any subject, rather than a completed notion. I 
know of no other term which, from its derivation, so accurately indicates the 
form of mental activity of which I desire to speak. 

66 



IMPERATIVE CONCEPTS. 6j 

condition. The predisposing cause in some cases may be 
an anaemic state of the brain, and in others a neurasthenic 
condition or one of irritable weakness, affecting unequally 
the different psychical centres, whose combined and normal 
action is essential to healthy mentality. Heredity is also 
an important factor, especially when it entails a general 
paranoiac condition of brain. It is, however, found in ex- 
perience that these concepts arise in many cases in which, 
apparently, neither of the above factors exist. They may 
arise from any cause which serves largely to increase or 
diminish the normal amount of the nervous energy of the 
system, such as shocks, profound grief, etc., and thus induce 
mental derangement. 

Mode of Origin. — The mode of their origin appears to 
be similar, if not identical, with that of hallucinations, ex- 
cept that in the imperative concept the impression or the 
irritation which gave rise to it is not projected, as in the 
case of hallucinations, toward the sensorial centres, but 
rather toward the psychical and motor centres, causing 
intense, peculiar, or irrational manifestations of manner or 
conduct. 

The character of concepts in relation to their physical 
basis depends, in the first instance, upon inheritance and 
educational influence; but beyond these factors they will 
depend upon the condition of the nerve-cells which consti- 
tute the psychical centres. This, again, will be influenced 
by the character of the blood supply and the evolution of 
nerve energy. In case the cells have been over-taxed 
during considerable periods, or have inherited a predis- 
position to instability, they become unable to recuperate 
and restore this expended energy during the usual periods 
of rest and sleep at night, and, in consequence, pass into a 
state of morbid weakness, irritability, and sensitiveness; 



68 LECTURES ON MENTAL DISEASES. 

they no longer respond in a normal manner to such 
stimulations and impressions as are received upon them. 
They become easily excited, and the concept to which the 
stimulation has given rise is no longer under the full 
control of the inhibitory centres ; it may be, and often is, 
projected into expression, even in spite of the will of the 
subject. 

Again, the morbid character of concepts may appear in 
their exaggerated nature and their tendency to usurp the 
field of consciousness to the exclusion of others, in conse- 
quence of local congestions and an unequal distribution of 
nerve energy throughout the different centres of the cortex. 
In the healthy condition of the brain, concepts arise in some 
order or system ; i. e. y they have an intimate connection 
with such subjects as the individual is engaged upon or 
has been thinking about and is directly interested in. In- 
deed, the more absorbing the interest, the more surely do 
concepts arise in direct relation to it. But in a weak or 
anaemic state of the brain the concept may arise suddenly 
without such connection and become imperative in its 
action ; the inhibitory centres being in a partially inactive 
or dormant state, the movement becomes largely automatic. 
Imperative concepts more often pertain to matters or sub- 
jects which have little or no relation to the recent mental 
experiences of the individual, unless in some remote degree, 
and they may arise from the excitation of memories relating 
to experiences long passed. 

Forms of Disease.— Imperative concepts are present 
more frequently in primary delusional insanity and melan- 
cholia, and are the initial element in the formation ot 
insistent ideas and morbid impulses. The degree of per- 
tinacity or persistency with which they continue to absorb 
and dominate the mental activities will depend upon the 



IMPERATIVE CONCEPTS. 69 

extent and character of the disorder of the brain, and, to 
some extent, upon the length of time during which it may 
have existed. They also tend to become more pronounced 
and dominant when they arise from the primordial character 
of the nerve elements which has been impressed upon the 
cortex by inheritance and the disorders and accidents 
incident to infancy and early childhood. 

Progress and Course. — It should be observed that these 
profound mental impressions may exist at times in the sane 
as well as in the insane brain, but in the normal condition 
of the brain they exercise only a limited influence. They 
may incite to acts and speech, but their influence is always 
modified by other mental concepts which are projected 
into the sphere of consciousness, and are under the control 
of the ego. With the insane their influence is so potent 
as to overshadow other concepts, usurp their sphere of 
activity, and lead to the formation of new ones, or even 
combinations of them. They wholly dominate the course 
of activities for the time being and influence the unhappy 
subject toward conduct of the most singular, absurd, or 
outrageous character. A female patient was brought to the 
Retreat, a few years since, who remained in a condition of 
apparent reverie during several days, and said very little, ex- 
cept in reply to questions. While in her room, one morn- 
ing, she suddenly thrust her hands through several panes 
of glass, which caused a considerable hemorrhage, and the 
blood covered her hands, face, and portions of her dress. 
She afterward said that the impulse to put her hands through 
the glass arose suddenly in her mind in consequence of the 
constant recurrence of that passage, "Ye have not yet resisted 
unto blood" and she adopted this means to do so. 

As new areas or paths of activity in the nerve-cells be- 
come implicated in the morbid process, these imperative 



yO LECTURES ON MENTAL DISEASES. 

concepts sometimes become harbingers of morbid impulses, 
especially when they arise in connection with painful sen- 
sations and a state of sadness. They may become the ele- 
ments which develop into sentiments of hatred and defiance, 
eventuating in vicious accusations and a desire for ven- 
geance for some fancied wrong, and in this respect lead to 
conduct which resembles that of a class of melancholiacs. 
The following case will illustrate the great suddenness with 
which these concepts sometimes develop; overwhelming 
even the consciousness for the time being and the possible 
consequence to which they may lead : — 

E. D. has been insane for several months, and had made 
a number of attempts at suicide prior to his admission to 
the Retreat. For some weeks subsequent to the last at- 
tempt he appeared to improve, when, on one occasion, 
while he was standing in his room, his attendant advanced 
toward him with the intention of passing, when he sud- 
denly drew back and struck him a blow which brought 
him to the floor. Immediately after it was over he apolo- 
gized, said he was very sorry and quite ashamed of him- 
self; he could not tell what had led him to strike, especially 
his attendant, with whom he was on the most pleasant re- 
lations, but the concept suddenly flashed upon and filled 
his mind as he saw him approach, and the impulse to strike 
became irresistible. Something of a similar nature occurred 
on at least one of the occasions when he had attempted sui- 
cide. He had been urged to go to the dining-room, where 
were seated several patients at the table, and went against 
his inclination. As he entered the room, he saw a carving 
knife upon the table ; the thought of suicide flashed upon 
his mind ; he seized the knife and made an attempt to cut 
his throat, but was prevented. As in the former experience 
with his attendant, when it was past, he was very sorry, 



IMPERATIVE CONCEPTS. 7 I 

and said he did not know why he had attempted to 
kill himself. 

In some cases the imperative concept leads to homicide 
as well as suicide, and in the above case there can be no 
doubt that if there had been a knife in the patient's hand 
he would have struck the attendant with it instead of 
his fist. When this is the case, and the suicidal or homi- 
cidal impulses arise from a brain in a condition of melan- 
cholia, they are among the most dangerous manifestations 
of that disorder, leading to unexpected attacks upon any 
person who may chance to be near at hand. The relation 
which the victim may sustain to the patient has no influence 
in restraining the act, and the dearest friend or child may 
be sacrificed with all the horrible atrocity which could be 
exhibited toward an enemy or an animal. 

It is doubtless true that the quality or character of these 
concepts depends somewhat upon the antecedents of indi- 
vidual experience and discipline of brain, upon the form of 
disorder existing in the brain centres affected, upon the age 
and sex of the subjects, and, perhaps, other elements of influ- 
ence. But yet, in the vast majority of insane persons, such 
concepts rarely eventuate in morbid impulses toward the 
injury of seif or others. When limited, they lead generally to 
an exaggerated mental activity in some one direction ; it 
may be in that of mischievous conduct, accusations, fault 
finding, or an endless repetition of trivial and indeterminate 
questions which are of little consequence. The concept fills 
and occupies the mind to the exclusion of others, for the time 
being, and leads to motor activity of a harmless, and often 
of an absurd, nature. 



72 LECTURES ON MENTAL DISEASES. 



INSISTENT IDEAS.* 

But these morbid concepts do not generally remain 
single or limited. They generally tend toward the forma- 
tion of special habits of thought. The same aspects and 
order of thought tend ever to recur in a kind of circle, 
from which nothing can change them. Even in health the 
exercise of the several portions of the brain tends to 
develop a peculiar disposition toward a repetition of such 
action. Mr. Herbert Spencer says that, " in the exercise 
of brain functions, lines of least resistance are gradually 
formed for nervous action by the repeated flow of nervous 
energy in definite directions." This is the case in a condition 
of health, — much more so is it when portions of the brain are 
in a neurasthenic, or supersensitive, or paranoiac condition. 
When, therefore, concepts have once arisen from any sub- 
jective or objective impression in such a brain, they tend 
more readily to repeat themselves in these paths of activity, 
until the will becomes quite unable to change them, or sup- 
ply their place with other concepts. Whenever the thought 
process begins, they thrust themselves, almost automatically, 
and often against the will, into the field of consciousness. 

Formation and Progress. — This, however, is but the 
initiatory stage. The concept increases in force by repeti- 
tion ; additional elements are added, until they combine into 
insistent and systematized ideas. The mind is no longer 

* I have used the term " insistent idea," as suggested by Dr. Edward 
Cowles, instead of " fixed idea," which has long been in use by writers. I 
regard it as preferable, as it more nearly describes the character of the idea we 
desire to study. Strictly speaking, an idea is never " fixed." Its nature appears 
to forbid this, but it may become ''insistent," and does so whenever it per- 
sistently appears in the field of consciousness and determines the subject-mat- 
ter and character of mental activity. — American Journal of Psychology, Vol. 
i, p. 222. 1888. 



INSISTENT IDEAS. 73 

wholly occupied with single concepts or impressions, but 
rather with the repetition of a considerable number, which 
leads to a purpose to do or not to do certain things. It 
seems wrong to follow a definite course of action ; to speak 
certain words or sentences, or to mentally repeat them ; 
hence, an effort to avoid them in every conceivable (and, to a 
healthy mind, inconceivable) manner. Mental reservations, 
vows and oaths are constantly made use of; the person can- 
not, or thinks that he cannot, reply to a question without 
first making some vow which will, according to his disor- 
dered reckoning, free him from all responsibility as to the 
result of his reply. 

Dr. Cowles relates a case, in which the patient was un- 
able to deliberately undertake any new act, however simple 
it might be, such as the buttoning or unbuttoning of his 
vest, without going over each step in the whole course of 
his mental operations which had occurred since morning. 
A strong effort on his part to do so would be attended with 
so much mental pain and anxiety as to cause perspiration 
to appear on his forehead, and increase the action of the 
heart and the frequency of respiration. 

The following case will illustrate not only the absurd 
character, but also the persistence of these ideas even after 
the lapse of years. A gentleman came recently to consult 
me, saying that he was greatly troubled from an experience 
which occurred nearly fifteen years ago. He was at the 
time living at a hotel, and upon going to his room late one 
night, which he had not visited during the day, found that 
the furniture had been removed, and that workmen had 
been engaged in painting and papering the room. They 
had not finished, and there were standing in the room two 
old cider barrels, which had been used by the workmen to 
stand upon. After going into the room and moving about 
7 



74 LECTURES ON MENTAL DISEASES. 

in it, he retired to another, where he went to bed, but the 
thought occurred to him that while he was in the room his 
coat had become wet with cider which had been in those 
barrels. This haunted his mind for several days, but he 
finally succeeded in dismissing it, and had not thought 
of the matter until within the past two weeks. He had 
not been sleeping well for some months, when lying awake 
one night, the old idea suddenly rushed into the field of 
consciousness again, and he had been unable to banish 
it for any considerable - length of time since. If, for a 
few minutes, he succeeded in getting his mind upon 
something else, he could not hold it, but he was con- 
tinually haunted, day and night, with the thought that 
his coat had, on that night, become wet with the cider 
which was possibly in those barrels, and that he must have 
worn it in that condition for months afterward. This idea 
has dominated nearly the whole course of his mind, until 
he appears worn and haggard. He says he fully realizes 
its absurdity, but is helpless in his efforts to prevent its 
intrusion. It appears that the taste, and even the smell, of 
cider have been especially offensive to him since boyhood. 
This fact may have some influence as a factor in the case. 

In other cases the sight of some particular person makes 
it necessary to go through the repetition of a series of oaths 
or vows to follow out certain courses of conduct in relation 
to him. This peculiar mental relation having become es- 
tablished toward the person, the course of conduct resolved' 
upon must be repeated again and again, lest some injury 
may come to him; and if by chance any unusual experience 
should occur, the patient at once accuses himself of being 
the cause ; something which it was necessary to do has 
been neglected, or, on the contrary, he has done something 
which he should not have done. 



INSISTENT IDEAS. 75 

Characteristics. — The morbid quality of the idea being 
dependent upon an irritable or supersensitive condition of 
some portions of the gray matter of the brain and its ten- 
dency to repeat organized processes, patients cannot be 
reasoned out of them, however absurd or improbable they 
may be. Discussion as to their absurdity which leads to 
a repetition of action in those centres which are affected, 
has little influence except to strengthen them, and in this 
respect they resemble some other elements of insanity. 
They arise from the involuntary exercise of the mental 
faculties in one or more of the disordered centres of thought, 
the imperative concept being the initial element, and the 
patient being quite incapable of substituting other subjects 
as against the depressive sentiments and suggestions which 
arise. They come into consciousness unsought and, be- 
coming subjective realities, may lead on to fully formed 
delusions and hallucinations, especially when the develop- 
ment is slow and steadily progressive. Some casual word 
or look from a stranger excites into activity a whole area of 
irritable nerve-cells and thus gives rise to erroneous infer- 
ences and beliefs. Insistent ideas are present in the forms of 
sytematized insanity, both of the exalted and depres- 
sive types. 

The following case will illustrate some phases of these 
peculiar ideas. The statement was written by the patient 
after her discharge from asylum life. She was for several 
years a patient in the Retreat, was then transferred to the 
Eastern Michigan Asylum, and remained there some six 
or seven years before she was finally discharged. The 
statement is quoted from the yearly report of the Superin- 
tendent, Dr. Henry M. Hurd: " When about twelve years 
of age I began to have strange fancies. On one occasion 
I thought the blood flowing from a cut finger would harm 



j6 LECTURES ON MENTAL DISEASES. 

those who came near me. I also had great trouble in 
dressing in the morning because whoever was in the direc- 
tion toward which my hand pointed when I put on my 
sleeves would be harmed. When walking out-of-doors I 
would often think I must retrace my steps, then go over the 
same ground again. This was caused by the same idea 
that some one would be in danger if I did not do it. After 
a time the thought occurred to me that my mother spoiled 
my food ; then I would eat nothing unless • I could do so 
without any one knowing where I ate. At last I feared to 
remain in the same room with my parents or sisters, or to 
allow them to know where I was. At night I would fasten 
the doors of my room on the inside, and then remove the 
bedding from the bedstead and place it on the floor in 
another part of the room and sleep there. I never feared 
little children, but was pleased to have them near me. The 
last named delusion I was not wholly relieved from until 
I was removed from home to a place where I was controlled, 
and, indeed, it was many years before I was entirely relieved 
from it. Before it was quite gone, the fear that I might 
come in contact with some contagious disease, and thus 
communicate it to others, took possession of my mind 
and dominated my conduct for many years." 

It will be noticed that this description of her morbid 
ideas by the patient extended over a period of several 
years, and that the character of the idea changed from one 
period to another, and at times was much more vivid than 
at others. The emotion of fear, evoked in the first instance 
from the imperative concept, appears to have been the 
foundation of her peculiar mental state. This is very com- 
mon with persons whose minds are so affected, and the 
conduct to which she referred was an effort she was con- 
stantly making to cleanse her hands and her person. . At 



INSISTENT IDEAS. 77 

times no one of the physicians of the Retreat, or any 
visitor or stranger, could pass through the hall where she 
was, and approach near to where she might be, that she 
would not immediately repair to the lavatory, and spend 
hours, if permitted, with soap and towels in an effort to 
remove any particles of possible contagion which might 
have passed to her hands from the visitors, and which she 
would afterward be in danger of communicating to others. 
Her intelligence appeared to remain quite intact, and she 
would occupy a portion of every day in reading. When 
reasoned with as to the absurdity of the idea of contagion, 
she would at once admit all that was said, but declare that 
she was unable to banish it from her mind or to refrain 
from an effort to avert the consequences to others. 

The emotion of fear, which in many cases depends upon 
an anaemic and imperfectly nourished condition of the 
cortex, appears to be the most common one which we meet 
with in this class of ideas, and may assume many forms or 
characters. The fear of certain places or situations is fre- 
quently described by writers, and special names have been 
coined to designate them, such as claustrophobia, agora- 
phobia, etc. A patient was for several years in the Retreat 
who, during long periods, was unable to retire to his room, 
either at night or in the daytime, without an effort to brace 
up the wall of his room with his back, lest it should fall 
and injure him, and, if permitted, would stand at times by 
the hour, with the most intense fear depicted upon his 
countenance, and with forehead covered with perspiration. 
The idea in his case, as also in that of the former one, 
seemed to approach the character of a true morbid delusion, 
but with this difference that it was inconstant ; it did not 
remain in consciousness or apparently exist there, except 
as it was evoked by his passing into his room. It did not 



yS LECTURES ON MENTAL DISEASES. 

become more than an idea; and the intelligence as to 
its absurdity was never impaired, though the capacity to 
banish the idea from the mind appeared to be wholly in 
abeyance. 

In nearly every asylum for the insane there are found 
cases in which the idea is limited to mere defilement. The 
sight of the hands or face, or any concept in regard to 
them, at once excites the idea that they are not perfectly 
clean, and that this is apparent to every one who is present. 
Hence they are all the while at the basin for the purpose 
of removing the imaginary dirt from the hands or face. 

There is no idea of contagion in these cases, as in the one 
described above. 

Ball* indicates not less than six forms which these insist- 
ent ideas and resultant delusions may assume, in his chapter 
on Folie dn Doute : — 

i. Les Metaphysicians. — Comprising those cases in 
which the patient is constantly seeking explanations in 
relation to questions which cannot be solved, such as the 
creation of Deity, or the origin of creation, etc. The more 
difficult of solution the problem may appear to be, the 
more intense the interest, and the tenacity with which the 
mind is occupied with it. 

2. Les Realistes. — Comprising those cases in which the 
patient is occupied with questions of the most insignificant 
and trivial character. 

3. Les Timores. — Who are in constant fear lest they 
shall do, or fail to do, some act, which in itself is of little 
consequence any way. They must act up to the very letter 
of some rule which they have prescribed for themselves, 
and, if they have failed in so doing, they must go over the 

* Ball, " logons sur les Maladies Mentales," pp. 494, et seq. 



INSISTENT IDEAS. 79 

process again and again until the very letter is fulfilled, lest 
some harm should come to themselves or others. 

4. Les Compteurs. — Who are constantly occupied in 
some form of calculation, such as the enumeration of 
objects they may have passed while on the streets, or the 
number of volumes contained in some library which they 
may have visited long before, or the number of persons 
who may have passed a certain house on the street. 

5. Les Scrupuleux. — Who pass their whole time when 
not asleep in the incessant fear of having spoken in a 
manner which was not perfectly true or accurate, or having 
harbored an evil thought against God, or some friend, on a 
former occasion. 

6. Les Malades Atteints de Delire du Toucher. — This 
class comprises those who are constantly in fear lest they 
have been contaminated by the touch of some unhealthy 
person or unclean object. They spend hours daily in the 
lavatory in vain and useless washings, to cleanse from 
imaginary dust, or some bacterian germs of disease. 

Besides the above, there are innumerable other forms 
which these insistent ideas may assume, and which admit 
of no classification. Individuals sometimes come to doubt 
their own existence and that of the universe about them. 
They have the idea that all is one vast hallucination or de- 
lusion, and they dare not move lest there be nothing on 
which to place their feet. 

It will, however, be observed that the above are not dif- 
ferent forms of mental activities, but simply different sub- 
jects about which the insistent ideas revolve ; and they 
will depend, to some extent at least, upon the antecedents 
of the individual as to education, environment, and sex. 
While the female mind may become absorbed by the fear 
of contamination, or of doing or of having done some- 



80 LECTURES ON MENTAL DISEASES. 

thing which should not have been done, yet it rarely or 
never becomes morbidly absorbed and dominated by ques- 
tions relating to the method of the existence of the Deity, 
or by the methods by which the universe was brought into 
existence. 

The various subjects about which insistent ideas may re- 
volve will be of importance chiefly as they pass over into 
systematized delusions, and the individuals become no 
longer able to modify or conceal them, and are led by them 
to commit imperative acts. Such patients may then be 
considered as in the genus of primary delusional insanity. 

The quibbles, contradictions, metaphysical tergiversations 
and delusions which these dominant concepts, and the re- 
sultant insistent ideas lead to, are sometimes almost in- 
credibly absurd and endless in variety. The following 
case that was in the Retreat several years ago will further 
illustrate these peculiarities. 

The patient, the son of highly intellectual parents, while 
reading in the Bible one day that portion which forbids the 
use of the blood of animals as food, became suddenly domi- 
nated with the idea that this command applied to him 
in all its original force, therefore he ought not to use 
any form of food in which blood existed, or of which it 
formed any part. But as the blood was the formative ele- 
ment of flesh of all kinds, the flesh itself must contain more 
or less of blood, therefore it was wrong to use any kind of 
meat. His idea was humored by his parents, and he was 
permitted to have all the eggs and milk that he could use. 
But the insistent idea remained and increased. He soon 
reasoned that as all the blood and flesh of fowls and ani- 
mals must come from the egg, therefore it also contained 
the element of blood, and he was disobeying the corn- 
man djust as clearly in the use of eggs as food, as in 



INSISTENT IDEAS. 8 I 

that of meat itself. Eggs were then discarded, and he con- 
fined himself for a few days to a milk diet. But he soon 
beo-an to arsrue that as milk was formed in a manner some- 

o o 

what analogous to that of blood, and as some cows at times 
give milk containing blood, there could be little doubt 
that in most quantities furnished by farmers there existed 
blood to some extent, or at least the elements of blood, 
and it was a violation of the command to use milk as 
an article of diet. He soon, therefore, discarded it, and 
determined to confine himself to a purely vegetable diet. 
He used for a short time oat meal and cracked wheat as 
being articles more likely to be pure. He, however, soon 
began to inquire as to the methods in which these articles 
were cooked, and unless the vessels used were new ones, 
and had never been used for any other purpose whatever, 
he would not touch the meal which had been prepared in 
them, lest there might have remained about them some 
blood-element, which had not been removed in cleansing 
them, and which had contaminated the food. New cooking 
vessels were obtained, and every means adopted to demon- 
strate that there was no possibility of there having been 
any blood in or about them. Yet it was but a short 
time before he came to the conclusion that it was wrong to 
use wheat or grain of any kind, without reference to the 
manner in which it was prepared, because in its growth it 
might have derived some element of blood from the ground, 
which had formerly fallen upon it and become absorbed by 
it. He was then brought to the Retreat, and a reasonable 
quantity of beef extract was soon afterward introduced 
into the "stomach. He did not feel very badly about this, 
as it was administered against his will and earnest pro- 
test, and therefore he was free from all responsibility. In- 



82 LECTURES ON MENTAL DISEASES. 

deed, I think he was really glad to have it administered, 
notwithstanding his protestations to the contrary. 

It was observed in the above case that, in proportion as 
the system became weaker from insufficient nourishment, 
the more insistent and persistent was the idea ; and, on the 
other hand, as the system became stronger from the forced 
alimentation, the domination of the idea became less, until 
it finally died away for the time being.* 

Treatment. — The treatment of such cases will necessa- 
rily depend upon the physiological condition of the system 
which may exist at the time being. When the system is 
well nourished and the abnormal mental state arises from 
hyperesthesia of the brain-centres of thought, the bromides 
of sodium and ammonium, either single or combined with 

* Krafft-Ebing mentions the following characteristics peculiar to this form 
of mental activity : — 

1st. The original morbid psychical excitability, because of which certain 
even futile exterior impressions leave a deep and lasting trace. 

2d. The exaltations of the fancy, by reason of which the images and ideas 
persist with morbid tenacity in the field of consciousness. 

3d. The increased activity of the association of ideas, from which the most 
distant relations immediately recall the morbid ones. 

4th. The enfeeblement of volitive energy. 

5th. The spontaneous organic origin of the ideas themselves, which come 
forth as if projected from the bottom of the inconscient. 

6th. The coincidence of their first appearance with somatic disturbances or 
causes (menstruation, pregnancy, the puerperal state, self abuse, protracted 
vigils, neuralgias), or with psychical causes (mental sufferings, misfortunes, 
etc.), causes all, and always, of neurasthenic action ; observing, however, 
that it is some exterior event that furnishes the point of departure and the occa- 
sional momentum of the anomalous ideation. 

Krafft-Ebing concludes that, from the spontaneous and organic mode in 
which the fixed constrained ideas arise in the mind, they constitute the most 
clear demonstration of the mechanism of inconscient psychical life. — " The 
Alienist and Neurologist" vol. v, p. 76. 



INSISTENT IDEAS. 8 



cannabis indica, may prove a most valuable remedy. But 
in the majority of cases which have come under my obser- 
vation, it has appeared to depend upon an imperfectly nour- 
ished and partially anaemic state of the brain. In such cases 
a generous diet of highly nutritious food is essential. This, 
with a large amount of moderate exercise in the open air, 
with the society of a judicious friend or attendant, and sup- 
plemented with firm moral management, will be a prime 
necessity. 

I must now refer to the moral management of such cases, 
which is of the highest importance. While a decided firm- 
ness is generally necessary, it should never be assumed that 
patients can fully modify and change their conduct at will, 
however absurd it may have become, or however capable 
they may appear of being able to do so. The difficulty 
experienced in passing from one line of conduct to another, 
or in advancing from one part of an action to the next in 
order, or, again, from one subject of reflection to another, is 
a profound one, and due to a morbid condition of the brain- 
centres. They cannot, therefore, be overcome by ridicule, 
or by insisting that they are merely imaginary difficulties. 
But firmness combined with large sympathy may be of as- 
sistance, and it will be better to assume that what is done 
is with the entire concurrence, if not at the request and with 
the approval of the patient himself. 

If the difficulty relates to the doing or not doing of 
something, such as the putting on or off a garment, or the 
going from one place to another, or the taking of food, it 
will be better to assume that the patient desires assistance, 
and proceed to give it ; or endeavor to divert his attention 
to something else for the time being rather than to insist 
upon his immediately doing the required act. If it refer to 
proceeding from one step in a mental process to another, he 



84 LECTURES ON MENTAL DISEASES. 

may often be aided by the suggestion of some intermediate 
steps in the process, or by the introduction of another 
subject quite foreign to that under consideration, and by 
leading the mind away from that in which the difficulty of 
transition has occurred. After the mind has thus become 
interested and changed in its current of thought and effort, 
it may again be led back to and pass on in its consideration 
of the former subject from a new point of view, and without 
difficulty. A frequent repetition of such a proceeding has 
sometimes proved of service in strengthening the control of 
mental operations, and in enabling the unhappy patient to 
govern his conduct. Such suggestions, however, will more 
generally prove to be merely aids in making life less un- 
happy for the patient, and more effective means will become 
necessary. 

One of these is regularity in physical exercise. I do 
not now refer to the exercise which may be obtained by walk- 
ing, which is largely automatic and does not require much 
attention, though this may be important in its way, but 
more particularly to the exercise of special muscles and 
groups of muscles of the various portions of the body, by 
means of calisthenic and gymnastic practice. In nearly 
all patients whose minds are largely occupied with and con- 
trolled by imperative concepts and insistent ideas, it will be 
found that little or no mental effort has been made for weeks 
or months outside of their subjective reveries and morbid 
tendencies. In consequence, the associating fibres which 
lead from the sensorial centres to the cortex, and which are 
essential to the normal discharge of the thought function 
when connected with any plan or subject which has been 
projected outside itself, have been left largely or wholly in 
a state of inactivity. Therefore the nervous energy of the 
system which passes to these elements of the brain, when in 



INSISTENT IDEAS. 85 

a state of healthy activity, is turned to other portions of the 
system. The blood-supply of these parts, which is also 
essential to the discharge of the usual amount of physio- 
logical functions, has become greatly lessened. In short, 
the same law holds true in reference to elements and areas 
of the brain which pertains to those of any other portion 
of the system, viz., that when an organ or element ceases 
to functionate, or largely diminishes its usual amount of 
function, it speedily tends to become weaker, and after a 
longer or shorter time becomes incapable of use. 

In seeking to restore the mind to its normal action, it 
will, therefore, be of the first importance to improve the 
circulation in the regions of these associated fibres and 
tracts of the brain, and also to increase the nerve energy 
to a normal standard. Now one of the most effectual 
means of securing this is by bringing into increased activ- 
ity the various muscles of the trunk and extremities. 
Exercise of almost any portion of the muscular system is 
attended with an increase of heart action, and consequent 
movement of blood, not only toward the parts more im- 
mediately concerned in the special action, but also toward 
the brain centres. The increased blood supply tends to 
enrich these nerve elements and restore the flow of nervous 
energy to them, and thus the two primary conditions for 
improvement are supplied. 

Moreover, exercise in the way of muscular movement in 
various directions tends to interest and engage the atten- 
tion, though the patient may not fully realize this himself. 
Indeed, it will often prove quite impracticable for one to 
remain in a class of six or ten persons, and observe the 
various movements of the bodies and extremities, which 
should always be timed to the music of some instrument, 
and not have the attention roused and the curiosity excited. 



86 LECTURES ON MENTAL DISEASES. 

In the majority of the class of patients now under consid- 
eration, the brain centres have not become so insensible to 
external stimuli that they will not respond. When wit- 
nessing almost any kind of symmetrical movement accom- 
panying the sound of music, there exists in nearly all 
persons a strong tendency to join in the movement, and 
they find it difficult not to beat time automatically with 
foot or hand when merely listening to music. 

Now I suggest that this tendency which exists in nearly 
every one to join in the movements of time and music be 
made use of with the class of patients I have been consider- 
ing, as one of the most effectual means of rousing the brain 
centres to a larger measure of healthy activity. A few 
movements for a short time at first, and slowly increased 
as to variety and length of time, will soon increase the 
power of attention, which is the most essential point. This 
gained, other and more diversified forms of activity will 
lead to further increase of mental power. 

These suggestions are in accordance with what has been 
found to be true of the brains of many of the chronic 
insane, which have remained in a semi-dormant condition 
for a long time. By means of associated labor they have 
been enabled to hold the attention for longer periods upon 
work, and mental operations have been improved. Prac- 
tically there will be found almost no difficulty in influencing 
a large per cent, of chronic patients to join with others in 
any form of work they may be capable of doing, simply by 
placing them in the company of others who are so engaged. 

The patient who will continuously and persistently refuse 
to join with others when engaged in some form of physical 
exercise or occupation, and at the same time remain with 
several others so employed, and with whom he is accus- 
tomed to associate, is the exception. 



LECTURE IV. 



DELUSIONS. 

Beliefs Dependent upon Education — Definition of Insane Delusion — ^Etiology 
— Diminution or Excess of Nerve Energy — Thought Elements of Dreams 
— The Character of Delusions Dependent on — Cases — May be either Ex- 
pansive or Depressive in Character — May be Transient and Imperfectly 
Organized or Enduring and Quite Fully Organized — Illustrative Cases — 
Other Elements of Insanity — Excitement — Depression — Incoherence — Ex- 
cess and Defect in Inhibition — Impairment of Memory and Will Power. 

Delusions are False Beliefs. Hallucinations are false 
perceptions. The first pertain to and grow out of the 
psychical functions of the brain ; the second depend upon 
the sensorial and psychical ; both may, and sometimes do, 
exist in cases of sanity. Additional descriptive elements 
of definition therefore become necessary in order to 
properly differentiate an insane delusion. 

First, it is important to distinguish between merely 
superstitious beliefs and insane delusions. There are few 
beliefs so absurd that they may not find lodgment in the 
brains of the ignorant, especially if they are regarded as 
having a religious character. Multitudes are yearly found 
who readily embrace ideas and beliefs which appear to be 
unsupported by evidence to ordinary minds, and evince 
the sincerity of their convictions by renouncing former 
modes of life, leaving family and friends for new homes and 
untried experiences. An announcement is made that an 
angel has been seen by a child in some locality, and thou- 

37 



88 LECTURES ON MENTAL DISEASES. 

sands flock together from long distances to see the place 
where the heavenly vision is said to have appeared. 

The mother in India believes it to be her duty to throw 
her newly-born babe into the Ganges, that she may perform 
a service acceptable to the gods which she worships. 
During the 16th and 17th centuries the belief in witches 
was very prevalent throughout Europe and to some extent 
in America. It is probable that many thousands were put 
to death in consequence of this belief, which had little other 
basis than a disordered motor activity in some cases and 
ignorance in others, and yet those in authority thought 
they were doing God service. 

As the character of beliefs depends largely upon the state 
of civilization and the quality of education existing in any 
society, it would be difficult to name one which would, 
under all conditions, be distinctly an insane delusion, or an 
act growing out of such belief which would in all cases be 
regarded as an insane act. In determining whether false 
beliefs are insane delusions, therefore, it is essential to con- 
sider them in their relation to the antecedents of the individ- 
ual professing them, the conditions of society in which he 
lives, and the degree of civilization with which he has been 
surrounded. A delusion, or an act growing out of it, might 
be an almost certain indication of insanity in one person, 
while in another it would have no such decisive indication. 

Again, beliefs in a state of health, whether delusions or 
not, usually arise from impressions acting upon the brain 
from without; on the other hand, an insane delusion always 
arises from within, that is, from the operation of disordered 
brain centres. Persons are rarely argued into insane delu- 
sions, or out of them ; they arise in consequence of a de- 
ranged psychical activity, and cease to exist only when this 
becomes changed or passes into a normal condition. 



DELUSIONS. 89 

The peculiarity, absurdity, or falsity of any belief, there- 
fore, is not necessarily a test of its nature. This must be 
determined by a careful study of, first, the person's past 
mental character and those influences which have been in 
operation to affect it, and, second, the method of its forma- 
tion and advent. 

Definition 1 : Insane delusion may be defined as a belief 
in that which has no foundation in fact, is at variance with 
the person's past mental history, and of the falsity of which he 
cannot be permanently convinced by any kind of evidence. 

Definition 2 : " Insane delusion is a belief in something 
that would be incredible to sane people of the same class, 
education, or race as the person who expresses it, this re- 
sulting from diseased working of the brain convolutions." 
(Clouston.) 

Many persons have delusions who are not insane, and 
conversely, some insane persons do not have delusions. 
Nevertheless, it is true that the majority of the insane 
have delusions during some period of the disease. So 
generally is this the case that they become one of the most 
important elements of insanity. 

Still, it should be borne in mind that delusions do not 
constitute insanity, nor, vice versa, is insanity delusion. 

Any special delusion which may arise in the brain hemi- 
spheres constitutes simply an evidence, so far as it goes, of 
a disordered process of cerebration. This disordered pro- 
cess may or may not ultimately eventuate in numerous 
delusions, or in some or all of the other mental processes 
to which allusion has been made on previous pages as 
constituting elements of insanity. The essential fact to be 
realized is that the brain is disordered in its process of 
functionating, and that the delusion may be merely a symp- 
tom of this fact. 



90 LECTURES ON MENTAL DISEASES. 

Method of Evolution. — Delusions of the insane not un- 
frequently arise from illusions. A person sees some one 
passing the door or window, and mistakes him for a friend. 
From this illusion arises the idea that the friend has come 
for him, and is desirous of removing him to his home ; and 
when the expected friend fails to appear, he begins to ac- 
cuse the physician of preventing him from so doing ; he 
believes his friend is waiting outside, or that he has been 
shut up in some room of the institution to prevent him 
from carrying out his purpose. This idea, combining with 
others which may be suggested by conditions or occur- 
rences, the cause of which he does not fully understand, or 
which arises from reflection upon what he has observed, 
grows into a settled belief or delusion which remains for a 
longer or shorter time, and no argument can convince the 
patient of his error. Or again, a patient may mistake some 
one passing by for an enemy whom he has formerly known, 
and conceive that he is looking about the institution for the 
purpose of arresting him and removing him to jail. The 
idea once having found lodgment in the disordered or 
supersensitive brain cortex, is strengthened by every un- 
explained occurrence which comes under observation, until 
it becomes a settled delusion so strong that he refuses to 
leave his room or the hall, will not go out of doors, asks 
if the windows are all secure, and begs never to be left 
alone lest he should be spirited away. 

In like manner delusions sometimes arise from halluci- 
nations. 

Miss N. has heard a voice which seems to her to come 
from outside the building nearly every night during several 
months. At times it is the voice of a female, at others of 
a male, and again there are two voices. She hears this 
voice distinctly, which tells her that its subject is there for 



DELUSIONS. 91 

the special purpose of keeping her awake and annoying 
her ; it also says that it intends to continue this annoyance 
until it drives her away from the institution ; that no one 
can prevent this proceeding, as the person is fully informed 
beforehand when any one is coming to interfere. This 
hallucination, with little variation, has existed for a long 
time and has given rise to the delusion that Miss N. has 
an enemy, or enemies, who live in the institution and who 
are determined to drive her away, and she begs to be pri- 
vately sent away that she may avoid their further attentions. 
Xo argument or demonstration of the impossibility of there 
being any persons who talk in this manner to her, or who 
are her enemies, has the slightest effect in convincing her of 
the falsity of the belief. 

There exists no question that insane delusions always 
arise from the disordered activity of the brain hemispheres. 
It may not be easy to demonstrate in what this disordered 
activity consists, but we must conclude that, as the co-opera- 
tion of the several elements comprising the psychical 
centres constitutes the physiological activity which exists 
in normal mental action, any failure in this co-operation 
would necessarily produce a diminished and deficient result. 
The conditions which would preclude the perfect union of 
activities in the process, we may fairly infer, would be of two 
kinds : First, a semi-paralysis of certain nerve-cells, or centres 
of mental action, in consequence of deficient nerve energy. 
This may be the result of diminished nutrition, imperfect 
assimilation, loss of sleep, excess of functional action long 
continued, combined with the toxic influence of waste 
products which have not been eliminated from the system. 
And, second, from an excess of functional discharge caused 
by a state of hyperemia of the organs. In the one case 
there would ensue a deficiency of local function, and in 



92 LECTURES ON MENTAL DISEASES. 

the other an excess of it in some of the centres concerned, 
and with abnormal or imperfect activity. 

The subject-matter of insane delusions is modified by 
and partakes of the stored-up memories or recorded effects 
of the past experiences of the individual. The revival of 
these memories or recorded experiences through the 
morbid activity of the brain-centres does not produce the 
normal reaction ; they do not perfectly combine into a 
whole, and the mental picture is blurred and distorted; its 
lights and shadows are not properly blended; the combi- 
nations of thoughts and ideas are partial and one-sided ; 
some have too much and some too little influence. Simple 
concepts may be accurate enough; ideas when taken by 
themselves may be true, but when these are all united 
into a whole for the purpose of establishing beliefs and 
conclusions or motives of action, the union is imperfect, 
and consequently abnormal results in the mind follow, in 
the way of delusions, which continue for longer or shorter 
periods, according to the intensity of the morbid excite- 
ment. 

At other times the concepts and ideas which go to the 
formation of a conclusion may themselves in some degree 
be defective and partial, and in consequence of this imper- 
fection exercise either too much or too little influence in 
their respective spheres in forming a whole. In this respect 
they may be regarded as in some measure like those which 
arise in the brain during dreams. It is extremely rare that 
the thought-elements of a dream are entire; indeed, they 
are nearly always imperfect, broken, disjointed, and non- 
sequential, and hence do not harmonize one with another 
and produce a conclusion which is symmetrical, and such 
as would be produced in a fully-conscious state of the 
brain. This is so nearly always the case in dreams that the 



DELUSIONS. 93 

mind has a kind of semi-conscious realization of its being 
so during their progress. 

Another illustration may indicate the character of the 
initial mental movements that are like those which lead on 
to the formation of insane delusions in a disordered brain. 

Almost every one is familiar with the exaggerated charac- 
ter of thought which appears in the field of consciousness 
when one awakes in the nightfrom a sound sleep, and 
while the brain is in a partially anaemic condition. When 
persons are light sleepers, oftentimes they do not readily 
fall asleep again, and find it quite impossible to do so for 
a considerable period of time. The thoughts, however, 
which occupy the attention are rarely of good quality, and 
it is seldom the case that the concepts which may pass 
through the mind in relation to any subject will result in 
a conclusion which will be satisfactory to the person after 
another sleep has occurred, and he has broken his fast and 
resumed the duties of the day. When the course of 
thought is ao;ain recalled, while the brain is in its full state 
of activity, and with its usual supply of blood, it is per- 
ceived to have been imperfect — exaggerated in some parts 
and defective in other parts, and that any conclusion drawn 
from it would, so far forth, be inconsequential, and thus 
resemble the first steps toward the formation of an insane 
delusion. 

The character of delusions will, therefore depend, to some 
extent at least, upon the past experiences of the indi- 
vidual, and upon the local centres of , the brain which 
for the time being are most active. The prevailing emo- 
tional state of the mind for the time being, also largely 
influences the character of delusive beliefs. When the 
mind is strongly under the influence of emotion, the fact 
that a belief harmonizes with that emotion is sufficient to 



94 LECTURES ON MENTAL DISEASES. 

commend it. For instance, the melancholiac who believes 
he has committed the unpardonable sin, is not depressed 
because of his belief, but has the belief in consequence of 
his emotional depression. 

It may appear somewhat singular that a deficiency in 
certain experiences which usually affect the emotional 
nature, should in any measure qualify or determine the 
character of delusions. Yet this will be found especially 
true in reference to the less permanent delusions of a 
religious nature. Many persons whose lives have been 
conspicuous for the absence of religious observances while 
in a state of health, yet when affected with melancholia and 
left to long periods of comparative isolation, have delusions 
which pertain almost exclusively to the subject, and are 
colored by this very failure of experience. Possibly they 
rise into activity from an hereditary influence transmitted 
by some God-fearing ancestor of a former generation. 
Delusions may refer to experiences as various as those of 
the history of the subject, and relate to affairs domestic, 
business, religious, or political. 

The following case is a good example of clearly defined 
delusions, which appeared to form very suddenly in an ex- 
cited state of the brain and which continued during several 
days. The person, who had not been regarded by his 
friends as " really insane," but " simply eccentric," went to 
New York, where he became considerably excited, and 
after two or three days to Brooklyn, where he had formerly 
resided. His brother, who had become anxious because he 
had not returned, went down to ascertain the cause of his 
absence. The following is the patient's account of what 
transpired after his brother found him : He says : " I was 
crossing the street at about eight o'clock in the morning, 
and heard some one shouting ' Ed ! Ed ! ' and sure enough 



DELUSIONS. 95 

up came Joe, out of breath and with eyes as large as a 
saucer. I saw in a minute that he was a lunatic. He began 
to say that we must go over to New York and take the 
first train for Hartford. I fell in with his whim, but told 
him that there was no hurry, as the train did not leave on 
Sunday until 4.30 in the afternoon ; but Joe would not be 
satisfied until I agreed to go, which I rather reluctantly 
did, as I had an engagement to play the violin in Henry 
Ward Beecher's church that morning. * * * I finally 
got him home, and in order to get him to sleep told him I 
was bound to go to sleep and he must do the same. I laid 
down and pretended to sleep until I thought he was asleep, 
and then I got up and went down to a drug store to get 
some atropine to counteract the effect of the belladonna I 
had taken with some beer, and just as I was ringing the 
night-bell, I looked around and there was Joe in the street. 
I at once gave up the atropine business, seeing how badly 
Joe looked, and told him that we must at once go to the 
police station. He said that we should not find any one 
there, but I insisted that we should, and there we went. I 
gave the policeman the wink about Joe, and he took in the 
situation at once and went right along with me to get Joe 
home. We had no trouble after that, but I tell you that 
I had to play sharp to get the whole thing through and not 
have him suspect me. I intended to get him home and 
have the policeman get him off quietly to the Retreat, but 
he said he was sleepy, and so I told him to go to bed and 
I would do so. I kept the policeman with me and sent Joe 
away to bed. I did not sleep much, however, but in the 

morning who should come in but Dr. and another 

policeman, and they proposed to take a ride. I thought it 
would be just the way to get Joe to the Retreat, and so 
agreed ; but at the last moment he backed out and they 



g6 LECTURES ON MENTAL DISEASES. 

drove away, saying they wanted me to see Dr. , and 

here I am. Well, they will have to pay the costs. I have 
lost $5000 by this operation, and ought this minute to be 
in New York on my secret detective business." The next 
day after his admission his brother called at the Retreat, 
but did not see the patient, who, however, saw him from a 
window as he was leaving and exclaimed, "There goes my 
poor brother ; he is as crazy as a bed-bug. I must send 
some one at once to the office to tell them to change the 
combination on the safe or he will steal all the assets." 

Delusions may be either expansive or depressive in 
character, according to the form of disease existing, and 
generally bear a relation either directly or indirectly to 
the individual himself. And finally, delusions may be 
transient and imperfectly formed, or persistent and fully 
organized. In the study of them, as exhibited in the 
wards of a hospital, we are impressed, first, by their 
character in relation to depression and exaltation. 

Miss G. remembers that she neglected the discharge of 
a duty in speaking to one of her friends years ago in rela- 
tion to religion ; the thought becomes a dominant one in 
the supersensitive condition of the psychical centres of the 
brain, and is constantly thrusting itself into the sphere of 
her conscious mental activity until it expands into a delu- 
sion. The imagined neglect of duty becomes a great crime 
for which she must be punished during eternal ages, and 
she persists in the constant iteration of the danger she is 
in day and night. Not long since she had the delusion 
that she had been the cause of permanent injury to the 
health of her little nephew, of whom she had had the care, 
because she had done, or failed to do, some trifling thing 
which was not of the least importance, and that there was 
no possibility of his ever being well again. 



DELUSIONS. 97 

Mrs. C, who has been a most devoted and affectionate 
mother and wife, is now a melancholiac. During the 
process of an almost constant introspection which has 
been going on, she has recalled some hastily spoken word, 
or an exhibition of temper on some former occasion ; this 
occurrence has been turned over and over in the circle of 
her mental activities until it has given rise to the delusion 
that she has been so sinful and worthless that not only 
her husband, but her children hate her, and are con- 
spiring to put her to death. In her disordered view, this 
is just and right so far as they are concerned, for she 
deserves nothing better at their hands. But she has no 
hope, either in this or the next world, and is too guilty a 
wretch to be thus summarily called to account. All asser- 
tions to the contrary are as idle words, while assurances of 
sympathy and anxiety for her recovery and happiness only 
add poignancy to her sufferings, while she still persists that 
she is unworthy of anything but hatred from her family. 

Mr. C. had experienced some unusual sensations about 
the abdomen, and he is confident that his bowels will never 
move again. He now refuses to take food because it 
will never pass from his system, and there will result an 
accumulation in the alimentary canal, until that will burst, 
to the horrible detriment of every one who may be near 
him at the time. 

Mr. B., who spent all his own property, and all belonging 
to his relations, which he could get hold of to spend before 
coming to the Retreat, and now has not got a sixpence to 
his pocket, says he is going to cover the corners of cer- 
tain streets, which were formerly owned by his grandfather, 
with elegant blocks of brick and stone ; that he will fill the 
rooms from cellar to garret with shelves, and the shelves 
with the most costly books ; that it shall be a free library — 
9 



98 LECTURES ON MENTAL DISEASES. 

free to everybody who may desire to read the books or 
lounge on the chairs and sofas he is to place for them. Only 
two days ago he was going to buy up all the watches, jew- 
elry, and diamonds which were to be found in the stores, 
and stock a first-class establishment which would be a 
credit to the city and himself, and where everybody, how- 
ever large his wants, could be supplied on the most liberal 
terms. To-morrow, or it may be next week, some new 
concept will enter the sphere of his mental vision. It 
will widen and deepen until a new delusion is formed which 
he will detail with more or less particularity. The old one 
will fade out and be forgotten, and when reminded of it, 
very likely he will look with suspicion or surprise, and 
declare that he never had such a belief. 

The delusions of the first two of these patients take their 
character from the form of disease existing, viz., acute mel- 
ancholia, and will fade away as will also others of a similar 
nature as they may arise, until improvement or recovery of 
the person. The delusions of the fourth patient described, 
though transient, yet are of the utmost importance, as they 
indicate a form of disease of an opposite type, and one from 
which persons do not recover, viz., general paresis. The 
latter portion of this statement, however, should be qualified 
by adding that, though this delusion may indicate a special 
genus of insanity, and actually existed in a patient affected 
with that form of insanity, it would be a mistake to base a 
diagnosis simply upon the exalted character of the delusion. 
Delusions of a similar character may arise from the func- 
tional activity of disordered minds, which are classed under 
other genera of insanity. The form of the delusion, therefore, 
in respect of diagnosis is of little value, except it be studied 
in connection with other symptoms which may be present. 

But in the further study of delusions we find those which 



DELUSIONS. 99 

have become quite fully organized in the mind, even to the 
minutest detail. The patient delights to explain and to 
defend their truth, however improbable they may be, and, 
indeed, the more improbable or impossible they may be, 
the more ready and persistent is the subject with an 
ingenious if not plausible explanation. 

Miss L. informs whatever physician she may be intro- 
duced to that she is married and is the mother of two 
children, from whom she is now separated, and always has 
been since their birth. One of them was born prior to her 
admission to the asylum, and the other since she has been 
an inmate. When questioned as to the circumstances 
attending the birth of the one in the institution, and how 
such an occurrence would be possible without the knowl- 
edge of any one about the ward, she replies that her 
husband, who is a physician, comes to the institution un- 
announced and without the knowledge of the physician in 
charge, and even before he enters the building, places her 
in a mesmerized condition, thus rendering her helpless. 
Then, through the influence of the wonderful mesmeric 
power which he possesses he is able to enter, pass through 
the halls and enter her room, notwithstanding she has 
locked and bolted the door and placed her trunk and two 
chairs against it. This he has done again and again, and 
when the time for her confinement arrived, he delivered 
her of the child and departed with it before she awoke, and 
he has never so much as written to her whether it was boy 
or girl, nor even its name. She regards it as an outrage 
that she is not permitted to leave the institution at once 
and assume the care of her two children, the first one of 
which was born in a similar manner before she came to the 
institution. She furthermore says that she was married to 
this man while in the same mesmeric state, and has never 



IOO LECTURES ON MENTAL DISEASES. 

seen him at all when in a waking condition ; that, in fact, 
he is a very mean and contemptible fellow to use her as he 
does, never once meeting her in a frank, cordial way. He 
always sneaks into her room at night by means of his mes- 
meric power and uses her person for his gratification, while 
she is utterly helpless by reason of the condition in which 
he places her, and then he sneaks off, leaving the door 
bolted and barred as if he had not been there at all. The 
difficulties attending any such marvelous proceedings all 
vanish in her mind at once before her explanation of 
the mesmeric influence this mysterious husband is able to 
exercise. 

This delusion has existed with very little variation for 
nearly two years, and yet the patient not only writes articles 
for the newspapers, but prepared an interesting and accept- 
able lecture which she delivered before an audience of two 
or three hundred persons. The fact of its long continuance 
clearly outlined in the mind without essential change of 
character, and with only slight modifications in some of its 
details, which tend to enlarge and perfect it, together with 
the fact that it has not been attended with symptoms of 
dementia, indicate that it is peculiar to Primary Delusional 
Insanity. One more illustration of the systematized form 
of delusion will suffice — 

Miss F., after an introduction and a few minutes of con- 
versation, proceeds to state that she is the daughter of one 
of the Earls of England. It is the old story, viz., that when 
she was only a few days old, her nurse was visited by 
another woman with a little babe of her own age, and when 
an opportunity occurred the strange woman changed the 
children, and thus she was carried away, and finally came 
to this country, where she has been ever since. She now 
says she has very gradually come into possession of the 



DELUSIONS. IOI 

true state of affairs, but did not fully understand all the. 
particulars until since she came to live in the asylum. She 
is under the impression that her reported mother informed 
her of some of the details while she was yet a child, and it 
is only since she has been here, and had opportunity and 
leisure to reflect and recall what was told her so long ago, 
that the whole truth has finally dawned upon her mind. 
She now has no doubt that, in process of time, she will re- 
turn to her native country and be restored to her rightful 
position as the daughter of her true father, the Earl, and 
she has been informed that a plan is already in progress 
to consummate this most happy issue of her unfortunate 
experience. 

The important distinction, then, in reference to insane 
delusions relates to their character in two respects. In the 
one case they are transient and imperfectly organized, 
and in the others they are enduring and quite fully organ- 
ized. In the one case they exist in the acute forms of 
insanity, and not infrequently change, and in the other they 
are found in the chronic forms, more rarely change, and are 
valuable aids in forming a prognosis. 

In both classes they may be of an exalted or depressive 
character, according to the form of disease in which they 
appear, and in the latter class the delusion may change 
from a depressive type into an expansive one, and vice versa, 
though much less frequently. Again, in both forms the 
delusion may relate to subjects of the most diverse and 
various character, which will depend, to some extent, upon 
the past history of the brain in reference to discipline and 
occupation. 

Delusions of an expansive character in primary delu- 
sional insanity may exist for years, and yet the mind 
retain a large measure of activity and intelligence, while 



102 LECTURES ON MENTAL DISEASES. 

delusions of importance and grandeur may exist in cases of 
hopeless dementia. 

The following case, which was seen by me in consulta- 
tion, and the statement of which the patient himself pre- 
pared at my request, will illustrate the elements of insanity 
we have now studied: — 

" Sunday night, June 10, 1888. On this particular day 
I ate a usual Sunday dinner at about 2 p. m., among other 
things some lobster, and drank a glass of milk ; was a little 
skeptical of the result at the time, as I had heard so much 
about people being made sick by the combination, but no 
trouble of that kind came of it. After dinner set down in 
my room, smoked, and read until I got sleepy. I then — 
although I feared that it might interfere with my sleep at 
night — laid down and went to sleep, from which I did not 
fully awaken until after seven o'clock. I then started out 
and took a leisurely walk, lasting about an hour; return- 
ing, I spoke to the family about a craving I was having 
lately for milk, and expressed a wish that I could get a 
glass of skim milk in the evening. Mrs. T. said I could 
have it, and insisted then and there upon getting a glass 
for me, which I drank and then went to my room, smoked 
a cigar, and read until ten o'clock, or after, when I retired, 
and experienced, as I feared I should, difficulty in getting 
to sleep. Eleven o'clock passed and the electric light was 
put out, making my room from semi-darkness to pitch 
black. How much longer passed I could not tell, as I had 
fallen asleep, when my senses were suddenly awakened by 
hearing T.'s voice, in the hall at my chamber door, just at 
the head of the bed, say in a sharp voice,* ' Stop popping 
beans at me ; I am no bean pole. Bo — bo.' 

* This may seem an unusual expression, but it is characteristic of the man. 



DELUSIONS. 103 

" Then commenced a struggle.- I can hardly describe 
the sensations. In fact, I hardly know what they were. 
It was not a smothering sensation ; I was held in a power, 
and the strength to throw it off was terrible, some part of 
which I was conscious of, and at other times — at short in- 
tervals — was evidently unconscious. In the last effort of 
the struggle I set bolt upright in the bed, and struck out 
with all my force, at what I could not tell, and then fell 
back, evidently unconscious, for how long I could not 
tell, but it must have been for only a short time, when I 
came to without further struggle and became wide awake. 
Then I remembered that when I was sitting up in bed the 
room was light with a subdued light. I lay very quiet for 
a time, listening very intently for any unusual noise and 
trying to account for the light, etc. With the exception of 
an occasional creak or snap in the floors, the location of 
which I could not place, heard nothing further. I then 
got up and made an examination of the windows and 
door, but found them as I had left them upon retiring. 
Went back to bed, and with the exception of an ' ahem ' 
from Eva nothing further occurred, and I soon went to 
sleep again. 

" At one time when I was stopping at the Metropolitan 
Hotel in New York I had a struggle of this kind. It 
seemed that during the struggle and in my semi-uncon- 
scious state, that I could outline some one part way through 
the transom over the door with a long stick having a 
sponge attached to the end of it, and just as I came out of 
the struggle I heard a noise just outside the door as of 
some one dropping down to the floor and making rapidly 
away. 

" Since the above date have kept my door locked at 
night. 



104 LECTURES ON MENTAL DISEASES. 

" October 7th. An attempt made again. This time I 
was awake. The effort must have been made with an 
atomizer through a crack in the door. First heard click 
of key in sitting-room door, then a step leading back to 
chamber door, and soon after realized I was being operated 
upon. 

" First appeared on that day with diamond stud. 

" Wednesday, December 5th. Was waked up in the 
night. Soon after heard a slight noise at my sitting-room 
door, which was followed in a few minutes by the old 
sensation of unconsciousness creeping over me, but fought 
against it without stirring. Distinctly felt atoms falling 
upon my face ; made an effort to throw it off for the time 
being, but I soon felt it coming on again, which was more 
than I could stand, and suddenly threw myself up in bed, 
thinking, perhaps, that some one was in the room ; but it 
came from over the door. Not disturbed further through 
the night. 

" Thursday, December 6th. Last night took precautions 
by fastening comfortable up in front of the door, back of 
head of the bed. Was awake again in the after part of the 
night, when I was startled by hearing a sissing noise at the 
top of the door, such as water forced through a syringe 
and coming in contact with a suspended cloth at close 
quarters would make. All was quiet for a while, during 
which time I heard the Methodist clock strike three. For 
the next hour and a half I lay perfectly still, during which 
time there were noises in the hall at my sitting-room door, 
and apparently in my sitting-room, but could not distin- 
guish any in my bedroom further than the door, and could 
not make sure of my man. My nerves were terribly tried 
at times. Twice there was a light in the room as if made 
by a lantern carried by some one on the street. 



DELUSIONS. I05 

" Had laid a trap in the sitting-room, but if they were in 
there they have caught on to it, which I had suspected was 
the case. About half-past four heard a click at sitting- 
room door, as if the lock was thrown back into position, 
after which everything quieted down. What did it mean ? 

" December 7th. After making a feint of going to bed 
last night, spent the night on the lounge in the sitting-room 
and was not disturbed. 

" December 8th. Frank B. and wife slept in the house 
last night. Went to bed, not hardly anticipating molesta- 
tion, but shifted my position to farthest edge of the bed — 
waked up in the night and turned over face toward where 
I usually lay, when I could detect an odor of some kind, 
but did not feel any marked effect from it, but at the same 
time, or soon after, detected some one at the door. Should 
think in this case that there was but one person ; kept quiet 
and feigned sleep as best I could; imagined there was 
something being thrown into the room, but, as I was evi- 
dently out of range, it had but little effect, if any ; heard a 
noise at the other door, but do not think that it was opened. 
After laying quiet for a while made a movement and made 
a few long breaths ; immediately heard a hasty step toward 
the stair landing, but kept quiet; after a time thought the 
dose was repeated ; lay there for what seemed a long time, 
when I made the same movement, etc., followed again by the 
hasty step; could not be positive of any further operation. 
After a time made a feint of waking and got up. 

" I imagine that they have caught on and are experi- 
menting. Feel stupid this morning. 

" Sunday, December 9th. Made arrangements with J. M. 
to watch with me last night, but learned in the evening that 
T. was sick in bed with toothache, so it was not considered 
necessary to-day. M. has declined to enter into it, giving 



106 LECTURES ON MENTAL DISEASES. 

several reasons. This throws me on my own resources 
again. 

" December ioth. Took precautions to protect my face 
last night, which was fortunate, as I was experimented with 
for two hours or more, commencing about one o'clock ; 
could form no idea which one of the family it was. They 
were unusually cautious. 

" B. and wife slept in the house. They took their de- 
parture this morning. 

" December nth. Had a conference last night with Dr. 
H. and Mr. M. by appointment made by them ; they 
advised nothing but what I have seen the necessity of for 
some time, but the question with me has been, when was 
the time ? I went to bed about half past eleven, taking 
unusual precautions. I had been in bed, perhaps, an 
hour, and had evidently dropped off into a light sleep, 
when I was awakened, now, I think, by the fumes of 
the anaesthetic used. I. soon discovered that an unusual 
effort was to be made, led on by desperation ; entrance 
was made into my sitting-room, and I could hear now 
and then a noise as if brushing against my mackintosh 
in the further part of room, near lounge. Every move- 
ment was made with deliberation — a snail's pace would be 
swift in comparison with the movements of the person 
in the room. No board would squeak under such a tread. 
Finally, they reached the bed-room door. In the meantime 
I was laying with pistol at full- cock; at the door they 
halted without getting in front of it. I had taken the pre- 
caution to throw the bed-room in the dark and sitting-room 
in the light, and placed myself with head at foot of the bed, 
with the door in line with south window, leaving the west 
window curtains part way up ; they evidently grasped the 
situation. In the meantime, in intervals, I would have to 



DELUSIONS. 107 

fight off a drowsiness. Finally I could detect an up-and- 
down motion, as if some one was working their arm up 
and down at full length across the door, but at no time 
showing their person. This was kept up for some time, 
and then ceased. All these movements were done with 
great deliberation, so much so that it was now approaching 
morning and my position in bed was becoming very irk- 
some, and I had to, at times, cautiously shift my position, 
which, I think, was finally detected, as I became aware, be- 
tween four and five o'clock, that the premises were vacated. 
Got up about five o'clock, and found the door closed; then 
went to bed in the usual manner, and laid on my side, and 
was breathing somewhat heavily as I noticed, but did not go 
to sleep. After, perhaps, half an hour I heard a step in the 
hall, first out toward the sitting-room door, then came to 
bed-room door, but whether anything was forced into my 
room I could not tell, as my face was protected and I was 
lying well on the edge of the bed, but thought so. I 
thought that it was about [time to end it, and spoke in 
concentrated voice, 'Now, you get out of that, G — d d — n 
you.' I hope the profanity was excusable under the cir- 
cumstances. They got out, and I went to sleep, sleeping 
until after eight o'clock. I did not see any of the family 
when I went down, and did not see any of them at noon. 
At night when I went in, Mrs. T. and the two girls were in 
the sitting-room. Eva gave a quick glance up as I stepped 
to the door, and then down on her work. Mrs. T. did not 
look up as I went in. Helen looked at her mother in an 
expectant manner. Finally, as I approached the stair door, 
Mrs. T. looked up, and, in a forced, pleasant voice, asked, 
' Does it rain now ? ' 'It does not rain now,' and I looked 
them over. When I came down to go to supper they had 
all disappeared. When I came back from supper they 



108 LECTURES ON MENTAL DISEASES. 

were not in sight. Later in the evening, concluded to 
keep my fire up, so lit a lamp and went down after a 
hod of coal. No one in the sitting-room — the dining-room 
was dark. As I went in Eva was sitting in the corner out 
of sight of any one. Passing out of sitting-room, Mrs. T. 
was in the act of stepping into the kitchen. Helen I did 
not see. When I came back from cellar they were in 
sitting-room, and were there when I passed out for the 
night. 

" Shall not sleep in the house again. Am satisfied that it 
was not intended I should leave the house alive. 

" This statement is deliberately made." 

Other mental phenomena, such as excitement, depression, 
elation, incoherence in thought and speech, excess of inhi- 
bition, as in stupor and catalepsy; defect of it, as in mania, 
simple enfeeblement of mental powers, loss of memory, 
will power, and acuteness of perception — are all elements 
of some forms of insanity. They, however, do not require 
any special description, and will be referred to in connec- 
tion with the symptoms of those forms of insanity in which 
they may appear. 

Treatment. — The treatment of delusions is that of the 
different forms of insanity of which they are an element. 



LECTURE V. 



CLASSIFICATION OF MENTAL DISEASES. * 

Early Classifications— Importance of ^Etiological Classifications — Morel — 
Schroeder van der Kolk — Skae — Clouston — Sibbald — Nomenclature — 
Names of Diseases may have been Accidental, or from the Symptoms 
and the Part Affected — Names Selected from the Leading Symptom 
Present — "Monomania" — "Paranoia" — Arrangement of the Different 
Genera of Insanity — Difficulty Attending it — Any Arrangement in Present 
State of Knowledge Must be Tentative — One Suggested. 

From the earliest history of disease much attention has 
been bestowed upon its nomenclature and classification. 
The Asclepiadse based their systems, and necessarily so, 
upon the most superficial indications, namely, symptoms. 
They knew very little, if anything, of the nature of those 
pathological conditions which arise under the influence 
and operation of disordered processes, while their anatom- 
ical knowledge was equally deficient. Hence, these two 
characters, which at the present time serve to so largely 
increase the sum of our knowledge, could not enter their 
ideas of classification at all. ^Etiology was still further 
removed from the range of their investigations, which were 
confined to such superficial indications of disease as were 
evident to simple observation. In process of time, however, 
the field of anatomy was opened, and as it became under- 
stood and widened the science of pathology was added, so 

* This lecture, revised, but essentially in its present form, appeared in 
The American Journal of Insanity ', January, 1888. 

IO9 



I IO LECTURES ON MENTAL DISEASES. 

that disordered conditions of the several parts of the body 
came to be regarded as essentially the starting point in in- 
vestigations of disease. The external manifestations, most 
of which are subject to large variations, even in the same 
disease, and some of which are common to diseases which 
are essentially different in their inception and character, 
came to be regarded as unsatisfactory as a basis of classifi- 
cation. The more permanent conditions existing in the 
morbid processes, and which serve to differentiate disease, 
thenceforth were regarded as forming a more reliable as 
well as scientific basis for the groupings and arrangements. 

Therapeutics, which if not the first point to be sought for in 
all our investigations and building up of systems, is certainly 
next to the first, was, by this proceeding, relieved from the 
most unsatisfactory basis of symptomatology and directed 
toward the more essential conditions of disease, it being 
recognized that remedies addressed to symptoms may have 
no influence upon conditions of which they are only the 
external and changeful manifestations. And in proportion 
as this course has been carried out have rational measures 
and proceedings succeeded more irrational and empirical 
modes of treatment. 

The old nomenclature was, however, not entirely dis- 
carded, but, on the contrary, much of it was retained, and 
we now have symptomatological names, such as paraly- 
sis, yellow fever, scarlet fever, etc., which were applied 
to them while the old basis of symptoms still obtained. 
This is not to be regretted, as changes of these names 
would introduce great confusion, and almost necessi- 
tate the study of disease de novo by those educated under 
former systems. Cullen says that changes in names of 
disease should be made only after the most careful considera- 
tion, and when the strongest reason exists for such changes. 



CLASSIFICATION OF MENTAL DISEASES. I I I 

Liebermeister long since pointed out the fact that the 
medical mind had been directed in more recent times to 
still another basis of classification, namely, that of aetiology, 
and indicated some of the very great advantages which had 
already accrued to the cause of medicine by an approach 
to its study on this basis. Whether we shall ever arrive at 
a knowledge of the causation of all forms of disease, we 
need not now stop to inquire, but it is quite certain that 
this is the goal to be sought for. Only when we arrive at 
the knowledge of the causation of disease can we have any 
basis of intelligent and rational treatment. In those cases 
where the cause is of such a nature as to be removed or 
avoided, the physician attains the highest of all triumphs 
in his profession. And even when the causes are of such 
a nature as to baffle treatment by prevention, we certainly 
can approach the conduct of disease from the most desirable 
of all points, namely, its ultimate. Therefore, aetiology 
and pathology must, in the future, from their importance 
as well as from their more permanent and unchanging 
character, form the true and ultimate basis of medical 
classification. 

In the field of general medicine this fact has long been 
recognized. Nearly all of the more modern writers upon 
systematic medicine have made large use of aetiological 
classifications, and we may anticipate that in the future, as 
our knowledge in this department of disease becomes more 
definite and extended, this course of procedure will be 
carried out still more largely than in the past. 

In the field of psychiatry Morel and Schroeder van der 
Kolk were the first to introduce and advocate the aetio- 
logical system of classification. Van der Kolk, however, 
thought that the terms mania, monomania, melancholia, 
dementia, and idiotism should still be retained in use, as 



112 LECTURES ON MENTAL DISEASES. 

they serve to distinguish better than other names the 
different forms ; but he regarded such a division as 
decidedly objectionable, because it was based on symptoms 
which are changeable rather than upon causes and origin 
of disease. He adopted two principal groups or genera, 
which he designated as idiopathic and sympathetic. The 
first indicated those cases in which the cause exists in the 
brain, and the second those in which the cause exists in 
other portions of the body, especially the abdomen and 
sexual organs. 

The first genus, A, included : — 

1. Acute Idiopathic Mania. 

2. Chronic Idiopathic Mania. 

3. Obtuseness. 

4. Dementia and Idiotism. 
The second genus, B, included : — 

1. Sympathetic Mania from disease of the colon. 

2. Sympathetic Mania from disease of the sexual 

organs. 

3. Sympathetic Mania from chest affections. 

4. Sympathetic Mania from erethica senilis. 

5. Intermittent Mania. 

In the form of sympathetic insanity there might exist at 
times a condition of mania, and at others of melancholia ; 
a condition of excitement or depression. 

Among English writers, Skae, though perhaps not the 
first to suggest, yet appears to have been the first to adopt, 
strongly advocate, and defend the system of serological 
classifications. He also enlarged what had been done by 
van der Kolk by the addition of several species or forms 
of insanity. This number, since his day, has been con- 
siderably increased by his pupils, Clouston, Sibbald, J. Batty 
Tuke, and others, and his classification has been adopted to 



CLASSIFICATION OF MENTAL DISEASES. I I 3 

some extent by those authors who have written systematic 
works on insanity within the past few years. That it is ever 
likely to wholly supersede Esquirol's nomenclature and 
orders I think its most sanguine advocates hesitate to claim. 
It certainly is not likely to do so until our means of investi- 
gating the nature of those changes which occur during the 
processes of thought while the brain is in a state of health 
have become more efficient than they are at the present 
time ; nor until the nature of simple derangement of mental 
activities is better understood. 

Our study of classification, then, leads into two divisions 
of the subject, namely, nomenclature and arrangement. 
Some remarks on these branches of our subject will now 
be in order. 

I. Nomenclature. — The selection of names for the differ- 
ent forms of disease affecting the several organs of the 
body appears to have been in some cases almost acci- 
dental, and without any purpose of a description of either 
its nature or the character of its symptoms. In other cases 
it has been founded upon the most superficial and easily 
recognized symptoms. In other cases still, it has been 
from the character of the pathological changes which are 
known to occur during its progress, or which are supposed 
to constitute its nature ; and, finally, from the character of 
its causation, and the name of the organ, or of the part af- 
fected. As examples of these several courses of procedure 
may be mentioned : — 

1. The Plague, Addison's disease, Basedow's disease, 
Graves' disease. 

2. Apoplexy, Yellow fever, Scarlet fever, Irritative fever, 
Rubeola. 

3. Bronchitis, Neuralgia, Pneumonitis, Bronchorrhagia, 
Tuberculosis. 

4. Malarial fever, Heat stroke, Bilious fever, etc. 



114 LECTURES ON MENTAL DISEASES. 

These few examples, selected at random, are sufficient to 
illustrate the statement as to the confused method made 
use of especially in the earlier nomenclature of disease in 
general. This lack of method or system has, perhaps, 
been unavoidable, as it has been desirable to furnish names 
to forms of disease in many cases in their earliest history, 
and before much was understood about them, except their 
most superficial indications, and when little was thought of 
in regard to consistency or plan of nomenclature; while, 
in more recent times, names have been selected having re- 
lation to both pathology and aetiology. This lack of sys- 
tem by early writers is of comparatively little importance, 
and not especially to be regretted except in those cases in 
which the name is false, or conveys a wrong idea as to 
either the symptoms, character, pathology, or aetiology of 
the disease. In nearly all of the above examples comprising 
the last three classes we have seen that the names do have 
reference to some one of the characters of the disease, and 
in many it indicates not only the character of the disease, 
but also the organ affected, both in a single word ; and in 
others still, it gives the cause as well as the nature and the 
organ affected. 

Now, in one view of the subject, it may be admitted that 
a name. is not of vital importance, as it becomes essential 
that the character of the disordered activity which consti- 
tutes that sought to be named must be studied and com- 
prehended by the student before he obtains that information 
which is to be of service to him in his future relations to it, 
and if the name is merely an arbitrary one, we may grant 
the claim ; but, if this is not the case, and the name has been 
applied under a mistaken idea as to the nature of the disease, 
or actually conveys a wrong impression of the character of 
its manifestations, then it certainly becomes a matter of 
importance, and may be enough so to warrant the changing 



CLASSIFICATION OF MENTAL DISEASES. I I 5 

of the name, even after years of use. For instance, if in 
yellow fever, it were found that those affected did not be- 
come tinged with that color any more than when in a state 
of health, or when affected with some other form of disease, 
it would appear to be absurd to continue the name at 
present in use ; if, in irritative fever, there has been found, 
after a more comprehensive study of the disease, that there 
exists no larger amount of irritation than in other forms of 
fever, or in other disordered conditions of the system, can 
we doubt that subsequent writers would modify or change 
the name, especially as these terms would then be mis- 
nomers, and convey wrong impressions? 

Examination then indicates that modern authors especi- 
ally have been guided in the nomenclature of disease very 
largely by its relation to symptomatology, pathology, aeti- 
ology, and the organs which may be its seat, and that in so far 
as practicable, they have sought to combine the several ele- 
ments of the disease into the name, and thus convey an 
idea as to the nature of the disease sought to be named. 
And further, that so far as the nature of the pathology and 
aetiology of disease has been understood when the disease 
has been christened, has the name been selected, not from 
the mere superficial indications of symptoms which have been 
the first to be observed and studied, but rather from the 
more permanent elements of physiology, pathology, or 
aetiology. 

With these principles of the nomenclature of disease in 
general in mind, we may now refer to two or three terms in 
use in the nomenclature of mental diseases. And, first, those 
which have been in use from its earliest history, and which 
Esquirol applied in his classification, viz., mania, melan- 
cholia, and dementia. 

The criticism of these terms by van der Kolk, as appli- 



Il6 LECTURES ON MENTAL DISEASES. 

cable to orders of genera of insanity, viz., that they indicate 
merely symptoms of disease and not any essential or per- 
manent element of character belonging to it, is as pertinent 
at the present time as it was then, and it has been repeated 
by many writers since his day. Indeed, Skae endeavored 
to abolish their use altogether as names of forms of disease, 
thus following in a general way in the footsteps of writers 
upon systematic medicine. But it has been shown that this 
has not been done in all cases by authors of works on general 
medicine, and that symptomatological nomenclature is still 
retained to some extent. Writers on mental disease therefore 
do not essentially differ from writers on other forms of dis- 
ease in this respect when they retain these terms to designate 
genera of insanity. Besides, pathological research has 
hitherto failed to demonstrate the nature of those changes 
which occur either in the texture or the physiological activi- 
ties of the brain, and which are the basis of either acute 
mania, melancholia, or secondary dementia ; and we are con- 
sequently in the dark at the present time, beyond the merest 
conjecture as to the nature of the pathological basis of these 
morbid symptoms. Reasoning from analogy and from our 
knowledge of physiological activities in general, we are 
confident that this basis is a disordered condition of certain 
elements of the brain structure; but until we understand 
more fully than at the present time in what this consists we 
are as helpless as Esquirol was when we attempt to attach 
any name to it which shall indicate its character. In his 
use of the terms he pursued a course exactly similar to that 
taken by writers on other forms of disease ; he applied" the 
name of the most patent and essential external manifesta- 
tions of these genera in each of the cases. The only other 
course open to him was the selection of a name entirely 
neutral or arbitrary in character, which would have been 



CLASSIFICATION OF MENTAL DISEASES. II7 

still more objectionable. So long as the terms yellow fever, 
scarlet fever, irritative fever, are in use by authors, writers 
on insanity need not be sensitive as to the use of mania, 
melancholia, and dementia ; and until we understand some 
aetiological or pathological equivalent for them we perceive 
no way by which they can be superseded as applied to 
genera of insanity. A few words in reference to the use 
of the term — 

Monomania. — Esquirol introduced this term to designate 
a species, rather than a genus, of mental disease. It would 
appear that, at first he thought there was a special form in 
which the disordered manifestations relate to one or a few 
subjects only, or in which a single faculty of the mind might 
be deranged. His writings on the subject, however, indi- 
cate, that while at times he used it in this restricted appli- 
cation, at others he employed it with a wider signification, 
and in such a manner as to cover a considerable variety of 
disordered mental activities, especially certain phases of 
chronic mania. However this may be, since the idea 
of partitions and divisions of the mind, one or two of which 
could be disordered, while all the others remained in state 
of health, has passed away, it has been applied to designate 
a special genus of insanity, which is essentially chronic 
in character, and which sooner or later exhibits derange- 
ment in many directions. It should be said that some of 
the features and characters of this genus of insanity have 
been brought to light, studied, and more fully differentiated 
by those who have succeeded Esquirol, and that these ad- 
ditional elements of the disease have only served to indicate 
more clearly objections to the use of this term monomania. 
I think there can be no question that they demonstrate 
that it is neither single in its elements nor maniacal in its 
manifestations, and that the term monomania is, therefore, 



Il8 LECTURES ON MENTAL DISEASES. 

untrue in both its primal and terminal compositions, and 
thus vitiates all principles of medical nomenclature. 

Whatever of excitement may exist in that genus of in- 
sanity to which it has been applied, is certainly very 
different in its character from that existing in mania. In 
the latter form of disease, the leading feature is lesion of 
the inhibitory centres of thought, and, consequently, there 
results an increase in the flow of words with more or less 
of excitement beyond what exists in a state of health, 
while in the former an opposite condition of mind exists. 
The thought is consecutive, and the opinions may be cor- 
rect, and frequently would be, if the premises assumed to 
exist actually did exist. The person does not often become 
excited, nor does he become convinced when the fallacy of 
his reasoning is shown ; but, on the contrary, he remains calm 
and unmoved in the face of the plainest exhibition of his 
folly', thus showing how profoundly his whole mental con- 
stitution is involved. Nor, again, does he become depressed 
and melancholy, when day after day passes, and he finds 
that his desires or plans to effect his wishes fail. He tells 
of his persecutions and the machinations of his supposed 
enemies with very little exhibition of excitement, or any 
deep apprehension as to the effects which are likely to 
ensue. It need not be said that all this is radically different 
from the depression of a melancholiac or the excitement of 
a maniac. The term, therefore, expresses a false character 
in the latter element of its composition as well as in the 
primal one, and, in consequence, has served to convey both 
to the laity and the profession incorrect ideas as to the 
nature of the disorder to which it is attached. If, however, 
it should be applied only as it is by some writers, to that 
form of mania which is sometimes sequential to its active 
form, and in which one or a few ideas of an exalted 



CLASSIFICATION OF MENTAL DISEASES. I 1 9 

character are more especially the theme of expression, the 
terminal portion would be more applicable. 

There is another term, which, though suggested and 
used to some extent by writers abroad, yet has more 
recently been introduced to the nomenclature of mental 
diseases in America. I refer to Paranoia. By some 
writers this has been used as a substitute for the mono- 
mania of Esquirol and by others for the broader Primaere 
Verruecktheit of the Germans. It is certainly difficult 
to understand on what principles of nomenclature this 
term can be applied to any genus of insanity. If the 
purpose was to substitute a Greek word for one derived 
from the Latin, and by its use avoid the English term in- 
sanity altogether as the name of an order of disease, all 
would be plain enough, but no such purpose exists. We 
have the term insanity as descriptive of a class or order of 
disease, and we are now seeking a name for a particular 
genus of that order, and it becomes obvious at once that a 
name which comprehends all that is understood by the name 
of the class or order under which it is to be arranged, will 
convey not only no accurate idea as to what is named, but 
is eminently misleading. It certainly has relations neither 
with a symptomatological, pathological, physiological, or 
serological basis of nomenclature, nor has it even the merit 
of a neutral character, as is the case when forms of disease 
are named after the discoverers, as Graves' disease, Addi- 
son's disease, etc. 

In a classification of disease, and translated into English, 
it would read as follows : — 

Order A. — Insanity. 
Genus I. — Mania. 
Genus 2. — Melancholia. 
Genus 3. — Insanity. 



120 LECTURES ON MENTAL DISEASES. 

This would be as scientifically accurate as for a natural- 
ist when classifying any order of birds — say that of ducks, 
geese, etc. — to proceed as follows : — 
Genus A. — Ducks. 

Species I. — Mallards. 

Species 2. — Teals. 

Species 3. — Wood Ducks. 

Species 4. — Ducks. 
Or, if again, in classifying the orders of fish, he should 
select that of eels, and proceed as follows : — 
Order A.— Eels. 

Genus 1. — Common Eels. 

Genus 2. — Electrical Eels. 

Genus 3. — Roman Eels. 

Genus 4. — Eels. 
I think that it may fairly be assumed that the wealth of 
terms which could be derived from the Greek, Latin, and 
English languages, when conjoined with the symptoms, 
pathology, or aetiology of any order or genus of disease 
which has .become sufficiently understood to be differenti- 
ated and described, will suffice to provide some name 
which may in a measure indicate its character. 

Instead of the term monomania, for reasons already pre- 
sented I would suggest another. And as the form of dis- 
ease is one without weir determined lesions of the brain, 
and whose proximal aetiology is not well understood, we 
are led to the character of the symptoms for its nomen- 
clature. Delusions, or a series of combined delusions, re- 
stricted for the time being in character and range of sub- 
jects, sometimes attended with hallucinations and at others 
not so, appear to constitute the primordial element of the 
disease. These delusions are peculiar as to their mode 
of origin. They are not the sequence or residue of 



CLASSIFICATION OF MENTAL DISEASES. 121 

former attacks of systematized insanity, such as mania or 
melancholia, nor do they arise in connection with such 
attacks, nor in consequence of any morbid habits of psycho- 
logical processes, which have existed in the former history 
of the individual. In other words, they are neither con- 
comitants of, nor secondary to other conditions of either 
excitement or depression. They arise, therefore, as primary 
elements of the disorder they characterize. We may, 
therefore, employ the term primary delusional insanity 
for this form of disease. 

II. Arrangement. — The other division of our subject 
relates to the grouping or arrangement of the several 
orders, genera, and species of insanity. The different 
systems devised and elaborated by authors have been 
almost as numerous as the authors, and have ranged from 
the simplest to the most complicated. If, however, the 
principles of classification in general, which have been 
referred to as guides in the nomenclature of the several 
forms, are correct, and can be of service in the arrange- 
ment of genera and species of insanity, certain other con- 
siderations which have been by some regarded as of 
importance may be dispensed with without much detri- 
ment. 

ist. The question as to whether a species of disease is 
curable or incurable will not be regarded as legitimate in 
forming any arrangement of groupings. The element of 
curability is very indefinite and uncertain in many cases, 
and involves a question which cannot be determined until 
after a long experience of treatment, and in some cases re- 
covery may occur long after the result has been regarded 
as improbable. Krafft-Ebing, while making use of " cura- 
ble " and " incurable " states as a basis in parts of his classifi- 
cation, places Primaere Verruecktlieit among the incurable 



122 LECTURES ON MENTAL DISEASES. 

forms, and yet in his monograph on this genus he admits 
that recoveries sometimes occur in persons affected with 
this form of insanity. I am unaware that this principle of 
classification is ever made use of in studying and arrang- 
ing groups of disease in general. 

Nor shall we regard the question, whether the disease is 
of such a character that a person who has once been 
affected by it is likely or liable to be so again, as of suffici- 
ent importance as to serve as a basis of arrangement, un- 
less there may have become established a neurosis, which 
may serve as an etiological basis for such a recurrence. In 
very many cases the question of recurrence will depend 
more largely upon the peculiarities of the individual in the 
way of inheritance, manner of life, character of vocation, 
ability to avoid exciting causes etc., than upon the charac- 
ter of the disease itself. 

Nor, again, will the question as to the relative numbers 
of cases which may be found in an order or genus, nor any 
system of " balancing " of these numbers so as to form 
a harmonious and symmetrical arrangement of the differ- 
ent forms, require attention. It does not appear how the 
matter of numbers, or whether we find one or one hundred 
cases of any form of disease in passing through the wards of 
a hospital, can possibly affect our inquiry as to the nature 
of the disease itself, or determine the genera under which 
it should be tabulated. An order may embrace one third 
or nine-tenths of all genera and species of cases and yet 
be founded on the only scientific basis practicable. The 
" clinical unity," which is to be sought for, should come 
from such an arrangement of the several orders and 
genera, as will depend upon the most essential causes and 
characters of the disease. But whatever course we adopt we 
shall meet with obstacles, which arise from various sources. 



CLASSIFICATION OF MENTAL DISEASES. 1 23 

One of the principal difficulties in arranging the different 
genera and species arises from the fact that upon whatever 
basis of selection we proceed there appear close affiliations 
and similarities of character. This is equally true in rela- 
tion to the symptomatology, pathology, and aetiology of 
several of the genera ; and the importance of these similari- 
ties will vary greatly in the minds of different authors, 
leading, consequently, to groupings according to the stand- 
point of the author. To one writer the character of a 
symptom, such as excitement or depression, or a diminution 
of mental function, will appear to be of sufficient impor- 
tance to lead to a different grouping of certain genera or 
species, while with another these changing conditions will 
be regarded as of less importance, and he will seek for 
a more permanent basis in some essential character. 

Again, when even these more permanent elements of 
character, such as pathology and aetiology, are selected to 
form the basis of groups, it will be found that the same 
genus may present a character, or arise from such causes 
as would lead to its location in either one of two or more 
groups. For instance, senile insanity will be regarded by 
one writer as simply a species of the genus dementia, and 
be arranged with the other dementias, such as primary, 
secondary, without regard to the aetiology or pathology ; 
while another will choose to regard it as a genus of the 
special order of epochal insanities, which will sometimes 
present symptoms of excitement, at other times of depres- 
sion, and at others still of dementia,jDut all of which have 
the basis of their origin in the physiological condition of 
a senile brain. One writer, regarding syphilitic insanity 
from the character of the degenerative changes which 
occur sooner or later in the nervous system of the patient, 
will arrange it with general paralysis in a group of patho- 



124 LECTURES ON MENTAL DISEASES. 

logical insanities, while another, regarding it from an aetio- 
logical point of view, will arrange it with the group of 
toxic insanities. 

Again, the relative importance of the several aetiological 
factors which may enter into the consideration of any 
order or genus of insanity may vary largely with different 
authors. In the ideal classification presented by Dr. Savage 
in his recent volume on insanity, it will be observed that he 
regards the physiological epochs of life as of prime impor- 
tance, and makes them the principal basis of his arrange- 
ment. By this method he relegates the proximal causes 
of genera and species to a secondary position, and intro- 
duces the same nomenclature for several species. Others 
regard these physiological epochs of less importance, as a 
basis of classification, and group the genera of insanity 
which arise in connection with them under one order only. 

Limitation in the consideration of any Genus of 
Insanity may lead to locating it in a relatively different posi- 
tion, or in a different order from that to which it would be 
assigned if studied under a wider signification. By this 
procedure syphilitic insanity may be limited to one species 
and regarded as a dementia, depending upon and arising 
from the pathological changes represented by the develop- 
ment of gummatous tumors in the substance of the brain, 
and infiltration of the membranes with syphilomatous de- 
generations of the brain arteries. If limited to this treat- 
ment it would be proper to regard and classify it with the 
pathological insanities. But if it be regarded as a genus, 
and as presenting a wider range of psychological characters 
and comprising several species, some of which are not 
attended with the same characters of pathological change 
as have been enumerated above, but which are dependent 



CLASSIFICATION OF MENTAL DISEASES. 125 

upon and arise from syphilitic infection, then it would be 
more appropriate to arrange it with the toxic insanities. 

In the same manner if alcoholic insanity be limited to 
that one phase of it, which has finally eventuated in a fully 
developed alcoholic neurosis, and is dependent upon 
changes in the brain which have become chronic, then it 
may-be arranged as one of the neuropathic insanities. But 
if it be regarded also as presenting an acute and a sub- 
chronic variety, both of which are attended with symptoms 
and conditions more or less peculiar to them, and are 
dependent more especially upon the acute and sub-acute 
effects of alcohol upon the nervous system, then it also 
would more properly be tabulated with the toxic insanities. 

In fact, the arguments for and against almost any com- 
bination and groupings of the several genera of insanity 
may be so numerous that it is quite impossible to arrange 
any system which will not present objections to some 
minds ; and it is very certain that when so many writers of 
the highest eminence have failed to agree upon what is the 
most desirable, the subject is attended with difficulties 
which are quite insurmountable in the present state of our 
knowledge. Our conclusion, therefore, is that for the 
present, and until we discover such means and appliances 
as shall enable us to determine more fully the nature of the 
normal physiological activity of that portion of the brain 
whose function is connected with the thought process, and 
until we can appreciate more fully and perfectly those 
pathological changes upon which mental derangement is 
supposed to depend, all our classifications of insanity 
must be regarded as merely tentative. 

The following arrangement will serve as a basis for these 
lectures, and I shall refer only to those forms which will 
probably most frequently come under your observation. 



126 



LECTURES ON MENTAL DISEASES. 



A. SYMPTOMATOLOGICAL. 



1. Melancholia. 

2. Mania. 

3. Primary Delusional Insanity. 

4. Folie Circulaire. 

5. Dementia. 



B. 



Epochal. 
(Physiological). 

2. 

Sympathetic 

(Sexual). 

3- 
Toxic. 



Neuropathic. 



5- 
Pathological. 



ETIOLOGICAL. 

Insanity of Puberty. 
Climacteric Insanity. 
Senile Insanity. 

Puerperal Insanity. 
Masturbatic Insanity. 
Ovarian Insanity. 

Alcoholic Insanity. 
Syphilitic Insanity. 

Epileptic Insanity. 
Hysterical Insanity. 

General Paralysis. 

Insanity from coarse brain disease. 

Acute Delirium. (Typhomania). 



6. ( Phthisical Insanity. 

Other less frequent \ sanity, 
genera and species. 1 Post-febrile Insanity. 



Rheumatic In. 



LECTURE VI. 



MELANCHOLIA. 

Two Classes of Mental Disorder — Definition — ^Etiology — Heredity — Sex — 
Climate — Age — Lithaemia — Moral Causes — Mode of Invasion — Symp- 
toms, Physical — Diminution of Nerve Energy — Effects upon the Voice 
and the Physiognomy — Increase of Action in the Vaso-Motor System — 
Loss of Flesh — Cutaneous Surface — Insomnia — Cephalalgia — Symptoms, 
Psychical — Morbid Self-consciousness and Introspection — Impressions — 
Mental Pain — Lack of Decision — Sphere of Thought Limited — Painful 
Sensations — Losses — Fear of Death — Fear of Becoming Insane, etc. — 
Periods of Depression which do not Eventuate in Melancholia — Stupor — 
May Arise as an Independent Disorder — Indications of its Approach — 
Symptoms — Movements Attended with Discomfort — Hallucinations — Case 
— Refusal of Food — Pupils Insensible to Light — Low Temperature — 
Sudden Changes in the Mental State. 

The departure of the mind from a normal state of activ- 
ity is more often than otherwise in one of two directions, 
viz. : toward a state of debility and diminution of functional 
activity, or toward a state of increased, though vitiated, 
function. 

These two classes of disorders are embraced under the 
general terms of melancholia and mania. The first is 
probably as old as any authentic history of disease itself, 
and was in familiar use by the earliest teachers. It may 
be defined as an affection which is attended with depres- 
sion, a tendency toward introspection, more or less of mental 
pain, enfeeblement, and partial prostration of the mental and 
physical faculties, with or without delusions. 

127 



128 LECTURES ON MENTAL DISEASES. 

iEtiology. — One of the most important factors in the 
causation of melancholia is heredity. This element exists, 
according to some authorities, in nearly sixty per cent, of 
all cases, and may come from either one or both parents 
or grandparents. It is regarded as more common among 
females than males ; this, however, is not in accordance with 
my experience. Doubtless the nervous system in females 
is more sensitive, and therefore more susceptible to the ef- 
fect of moral impressions of all kinds ; but, on the other 
hand, the male, as the bread-winner, or financial agent of 
the family, is more exposed to the effects of reverses in 
business and the consequent worry and anxiety than the 
female, whose sphere of activity is more limited. 

Melancholia occurs more frequently, and affects the 
system with greater intensity, between the ages of thirty 
and forty, but when inherited more often occurs at the 
critical periods of life — puberty and the grand climacteric. 
According to Dagonet, it exists more frequently among 
the inhabitants of northern climates and of mountainous 
regions, than among those residing in warmer climates. 
Disappointments, excessive mental application and strain, 
reverses in business, masturbation, loss of property, loss 
of children, anxiety in any and all its forms, and, in fact, 
any of those experiences and conditions which tend to 
weaken and especially depress the nervous system, may 
act as direct causes in the development of the disease. 
An additional factor in its causation is doubtless a de- 
ficiency in the elimination of the products of secondary 
changes in the elements of the tissues, and a consequent 
vicious quality of the blood. It may also, to some extent, 
arise from that systemic condition which has been termed 
uricaemia, or lithsemia. The products of a deficiency of 
oxidation act as irritants upon the nervous centres, and 



MELANCHOLIA. I 20, 

prevent the supervention of that condition of the brain 
which is necessarily incident to sleep. They may also be 
an active factor in the causation of mental depression and 
the emotional disturbances which sometimes occur with- 
out melancholia. 

Mode of Invasion. — This disorder rarely becomes sud- 
denly developed. There usually exists a considerable period 
of incubation, during which changes of mental condition 
may occur, such as vague apprehension, unusual irritable- 
ness, or alternate states of depression and hopefulness. The 
length of time during which the latter state continues 
tends to become shorter ; the person loses interest in his 
usual work, and, finally, abandons it altogether ; remains at 
home, is silent and unhappy, and cannot be induced to seek 
for amusement or change, nor to engage in much active 
exercise of mind or body. The sphere of normal mental 
activity becomes transferred from the external or objective 
world, where its enjoyment has more largely existed, to a 
subjective one ; and here it tends constantly toward a more 
and more limited field, and in proportion as this occurs 
the intensity of mental pain is increased. 

The period during which these prodromatous condi- 
tions exist may vary very considerably. It usually extends 
over several months, and may extend over years. The 
individual is generally at first fully aware of the changed 
state of his feelings, but shrinks from making it known to 
others. He is able to follow his usual occupations ; his 
mind is clear in reference to his relation to duties, but, 
especially when alone, is filled with painful emotions. When 
reminded that he becomes unduly absorbed in his own re- 
flections and is unmindful of his relations toothers, he may 
make an effort to resume his former habits of thought and 
action, but this is successfully done only for a longer or 



I30 LECTURES ON MENTAL DISEASES. 

shorter period, according to the degree of impairment in the 
physiological activities of the emotional centres. 

M. D., age fifty-nine, when admitted to the Retreat, was 
reported to have been in this state for more than two years, 
despondent at times and anxious, and yet had, up to within 
two months, attended to his usual occupation and slept well. 
These mild and initiatory attacks are often relieved by 
periods of rest and change of occupation and diet. 

Symptoms — Physical. — The physical symptoms of mel- 
ancholia are much more definite and characteristic than 
they are in many other forms of mental disease, and as these 
physical conditions are, without doubt, largely the cause of 
the mental symptoms, it is desirable to carefully note and 
examine some of the more important in detail. 

One of the most marked characteristics of the melan- 
choliac is the change in his general appearance and attitude. 
This distinguishes him at once from persons affected with 
other forms of mental diseases, even to one who has had no 
experience in the study of insanity; it arises from two 
causes. 

The first is a partial paralysis of, or a diminution in, the 
normal amount of nerve-energy in the cerebrum and the 
motor-system of nerves. Locomotion requires a greater 
effort on the part of the individual, and is attended with a 
feeling of lassitude and weariness ; movements are as few 
as possible, and are made slowly or not at all ; the gait is 
unsteady, and the arms hang loosely by the side ; the per- 
son may sit for hours with almost no movement if permitted 
to do so, and remain silent with eyes fixed upon the floor 
or gazing upon the wall before him. He sometimes will 
remain in bed unless forced to arise, and often requires to 
be dressed and forced to take exercise, if he has any. 

This diminution of nerve-energy extends to the laryngeal 



MELANCHOLIA. I3I 

muscles, and renders the voice feeble and indistinct. It 
often appears very difficult for the person to articulate per- 
fectly, and it requires so much effort that he answers ques- 
tions, if at all, only after they are repeated perhaps several 
times. The muscular fibres of both the large and small 
intestines sympathize with the general debility of the mus- 
cular system, and, in consequence, the peristaltic action of 
these organs is greatly diminished. Hence, one of the most 
persistent and annoying of the physical symptoms, costive- 
ness, is generally present. 

The physiognomy is changed, and the face seems to be 
larger ; the head falls forward when the patient is either 
sitting or walking, the orbicular muscles become relaxed, 
and the eyes are sunken in the sockets, and appear larger 
than usual. 

Second : On the other hand, there exists an increase 
of action in the vaso-motor system as compared with that 
which is present in health, in consequence of the usual bal- 
ance — which exists between the two systems of nerves, and 
by means of which the circulatory and nutritive systems 
are enabled to act freely and normally — being deranged. 
The small arteries and capillaries become constricted, and 
the amount of blood passing through them lessened ; the 
nervous tissues and organs of the body are imperfectly 
nourished, and the person looks pale and thin in the face, 
perhaps more so than he really is. The action of the heart 
is diminished in force and frequency ; the pulse is weaker, 
and there results a corresponding diminution in the circu- 
lation of the blood to the internal organs of the body, and 
also a change in its quality which doubtless leads to a les- 
sening of the secretions and excretions. 

The mouth becomes dry and the tongue coated, and has a 
bitter taste; the appetite is diminished or altogether absent; 



132 LECTURES ON MENTAL DISEASES. 

the usual satisfaction which arises from the use of food and 
its presence in the stomach is gone, and an indifference in 
regard to it, or an actual loathing of it, results. This becomes 
so fully pronounced, in many cases, that they rapidly become 
weaker and thin in flesh, and would approach actual starva- 
tion if resort was not had to forced alimentation. Even 
when food is received with regularity, it appears to be only 
partially digested or assimilated, and the body is imperfectly 
nourished, while the subcutaneous adipose tissue becomes 
rapidly absorbed. The mucous surfaces of the bowels tend 
to become dry, which increases the difficulty in obtaining 
their evacuation. The urine is scanty and high colored ; 
the ordinary amount of perspiration and secretion of the 
sebaceous follicles of the skin, though increased in the early 
stage of some cases, are generally greatly diminished, and 
there results a dry, harsh skin and hair. 

The whole cutaneous surface is partially anaesthetic in 
some cases, and it appears to be almost insensible to the 
effects of heat and cold, bruises and contusions ; the hand 
will be placed in a flame or on a steam pipe, and held there, 
if permitted, until the tissues are destroyed, with little or no 
indication of pain. In the cases of females, menstruation 
ceases altogether, and the sexual appetite is in abeyance in 
both sexes. 

One of the most conspicuous consequences of the de- 
rangement in the circulation of the blood in the different 
internal organs, and the supersensitive condition of theideo- 
motor centres of the brain, is insomnia. This is one of the 
most constant of melancholiac symptoms, is very persistent, 
and is present in almost all cases sooner or later. The con- 
dition of the brain giving rise to it is sometimes realized by 
the patient, and is the cause of much apprehension and suf- 
fering ; and, even when sleep is induced, it is often attended 



MELANCHOLIA. 1 33 

with unpleasant dreams and a semi-conscious apprehension 
of something dreadful about to happen to the person. He 
awakes in a short time, or in a few hours, with a feeling of 
uneasiness and lassitude, as if he had not slept, and fre- 
quently declares that he has been awake all night. 

Cephalalgia is another symptom which is present in a 
considerable number of patients, more especially in the 
early stage of the disorder, and especially in the early part 
of the day, or for a period after awakening from sleep, and 
there can be but little doubt that it arises from the changed 
conditions of the circulation of the brain or from the exist- 
ence of oxaluria or uraemia. In many cases the abnormal 
sensation does not amount to actual pain, and the patient 
complains of a " vacant " sensation, or one as if there was 
external pressure on some particular spot, which may con- 
tinue for some hours, passing off before the patient sleeps. 

Some or all of the above physical symptoms may exist 
in different cases in varying degrees of intensity, and there 
will generally be found a considerable measure of corres- 
pondence between their severity and extent, and those of 
the psychical condition which may be present. 

Symptoms — Psychical. — The mental symptoms in mel- 
ancholia vary even more largely in different cases than do 
the physical, and have led to the arrangement and presen- 
tation of several varieties of the disorder by different 
authors. These mental symptoms will be found also to 
have some special relation to the physical conditions, and, 
indeed, appear to be the legitimate outcome of them, at 
least in the milder forms of the disease. There exist, 
however, no clearly defined lines of division between these 
varieties. On the contrary, they fade insensibly into each 
other. But, for our greater convenience, we may refer 
to the characters as they appear under several classes 



134 LECTURES ON MENTAL DISEASES. 

of cases ; and, first, that of simple melancholia, or the 
" melancholia avec conscience" of French authors. 

One of the primary, most obvious, and persistent of the 
mental symptoms is that of morbid self-consciousness and 
infrospection. The mind seems no longer to reach to its 
environment for satisfaction or enjoyment. It no longer 
delights in the social or family life which has before held 
so large a place in its affections. The patient turns away 
from friend, family, and former interests, and shrinks within 
himself, broods, and feeds upon his past experiences, which 
are soon all converted into failures and mistakes, or even 
into criminal acts. This leads to an indifference toward 
or a positive dislike of the usual pursuits and avocations 
which have been followed, perhaps during long years. 
The world-life without no longer presents its former 
attractions, and he finds it very difficult or quite impossible 
to project his thoughts and purposes from himself enough 
to enable him to concentrate them upon the necessary 
details of arrangement, and thus render the accomplish- 
ment of labor either easy or satisfactory ; he, therefore, 
turns from it with weariness or loathing. 

A step further, and this intense introspection leads to a 
dislike toward former friends and even nearest relatives. The 
husband becomes indifferent toward the wife and the wife 
toward the husband, the child toward the parents and vice 
versa. The miserable failures and mistakes which have been 
so long and so constantly made, according to the disordered 
mental reckoning of the patient, must, in the natural order, 
have long since alienated all old friends, and their profes- 
sions of interest and love now weigh for little or nothing in 
his consideration. 

The changed condition of the circulation, eventuating in 
a largely diminished supply of properly aerated blood, 



MELANCHOLIA. 1 35 

appears to result in a supersensitive condition of some of 
the higher brain centres. They are correspondingly easily 
affected, and impressions conveyed to them from without 
are increased in force, resulting in the formation of con- 
cepts in the mind which affect it with an abnormal degree 
of intensity ; the person is irritable, impatient, and dis- 
inclined to yield to the requests of others. 

There may not be enough of the morbid element to 
amount to a delusion in the character of the concepts 
themselves ; they may develop from the basis of the 
normal association of other concepts, and would themselves 
be normal except for the sensitive state of the brain centres. 
But, arising in connection with such an abnormal condi- 
tion, they are accompanied with unusual experiences. 

One of these is mental pain. When persons are in a 
condition of health, the thought-process transpires almost 
or quite automatically, except as influenced by the will, 
and certainly is not attended with painful feelings. With- 
out doubt there exist different degrees of brain sensitive- 
ness in different persons when in health, so that similar 
impressions from without may be of such a character as to 
cause varying degrees of painful emotions. Young per- 
sons are usually more sensitive than older ones, women 
than men, and some women more so than other women. But 
in the melancholiac there has occurred, in this respect, a 
change from that condition of brain which is normal to the 
individual, a change resulting in such a state of the brain 
that the ordinary process of thought and the formation of 
concepts is attended with an element of pain, which the 
patient is nearly always conscious of when awake. It is, 
however, without any adequate cause in the environment of 
the individual. 

There may also exist an inability to come to any final 



I36 LECTURES ON MENTAL DISEASES. 

conclusion or determination in reference to subjects occupy- 
ing the mind or in reference to requests presented. Some 
arguments for and others against a certain course of 
conduct are constantly thrusting themselves forward into 
the field of consciousness, thus rendering the person un- 
certain and confused as to what should or should not be 
done ; while efforts on his part to come to a decision are 
attended with painful sensations in certain portions of the 
brain. Doubtless there exists in some of these cases a 
hyperaemic condition of the membranes of the brain, 
attended with an abnormal amount of nerve energy in those 
brain centres which preside over the emotions. 

Another change in the character of mental activities con- 
sists in the tenacity with which any concept which has once 
arisen in the brain, and which is in harmony with the pre- 
vailing emotional state, holds on its course, refusing, as it 
were, to yield its place to others. Largely in proportion as 
the subjective consciousness increases, the sphere of 
thought appears to be circumscribed and limited to one or 
a few subjects only, and the concept or purpose revolves 
again and again, returning through the same brain chan- 
nels of mental activity, and every effort which the patient 
can initiate for its removal, or to replace it by others which 
relate to other subjects or persons, fails for the time being. 
And if in the process of time, by means of a change of scene 
and association or other strong influences and impressions, 
this concept loses its hold and fades away, some other 
arises, takes its place and remains with a like force and tena- 
city. Hence an almost mulish obstinacy and indifference on 
the part of some patients. They refuse to be moved or per- 
suaded ; they will not dress or undress, retire to bed or get 
up, take food or drink, except as they are forced to do 
so, while the field of consciousness is filled with an ever 



MELANCHOLIA. 1 37 

increasing round of irrelevant thought, attended with 
pain. 

Impressions upon the end organs of sense reach the sen- 
sorial and intellectual centres and eventuate in speech and 
motor activity more slowly than in health. The same fact 
exists in dementia, general paresis, and in some other forms 
of insanity, but it appears to be more especially character- 
istic of melancholia, though it is not practicable to accu- 
rately demonstrate by experiment the amount of change 
which has occurred in this respect in any individual case. 

The morbid element, therefore, in the character of the 
thought process, and its resultant concepts, relates to their 
persistence, intensity, and the attending painful sensations ; 
and these modified characters will be discovered in the 
multitudes of experiences, beliefs, and actions, which are 
generally present in cases of melancholia, covering the 
whole field of mental activities. They not infrequently 
have a basis of truth and develop from some of the actual 
past experiences of the individual, especially during the 
early periods of the disorder. When this is the case, they 
may refer to past occupations, associations, domestic dis- 
appointments and afflictions, or to the subject of health. 
One may have met with reverses in business, or lost a 
child or other relative by death. This experience and its 
attendant circumstances occupy the mind night and day, 
giving rise to a multitude of self reproaches and vain mis- 
givings. He thinks and says, " If only I had pursued such 
and such a course of conduct, all would have been well." 
Another is haunted with the idea that he is financially 
ruined, and will never be able to meet his obligations*; that 
he has disgraced himself and forfeited all claim to the 
respect of his former associates ; there has never been any 
honorable motive in his business transactions ; and the 
time is not far distant when his miserable delinquencies 



I38 LECTURES ON MENTAL DISEASES. 

will all become exposed to his neighbors and friends ; then 
his good name, of which he has thought so much, and 
the reputation he has sustained for so many years, will 
vanish into emptiness. Another is haunted with the fear 
of death. He realizes that he is not well, that he is miser- 
able, and is confident that the illness is to be fatal, and that 
the sufferings of a future world are awaiting him. An- 
other, still, is haunted with the fear that he is to become 
insane very soon. He is not so now, but the time is near 
at hand when he will become only a dement. He consults 
his physician, explains in some measure his morbid and 
painful forebodings, his despair of ever being any better, and 
ends with the statement that he is confident he will soon be 
insane, and fears that he will be sent to an asylum ; he begs 
that he may be saved from such a sad fate. 

In short, the whole field of mental activity appears to be 
filled, so far as it is filled with anything, with these morbid 
ideas and delusions. Dr. Clouston, in his clinical lectures 
upon Mental Diseases, enumerates more than fifty of these 
different delusive beliefs, which have been noticed in 
patients who have been under his observation. In process 
of time the whole intelligence becomes profoundly affected, 
and all volitional power to act is suspended. The' self- 
accusations repeat themselves over and over ; the person 
is ruined or lost forever ; he has committed the unpardon- 
able sin, and will be eternally consigned to punishment ; 
he will never recover; or, he has been defrauded, or poi- 
soned, etc., etc. The tendency in such cases is toward a 
condition of stupor rather than one attended by delusions 
of persecution. Hallucination of the special organs of sense 
are rare, except in the more advanced stages, the conditions 
of which are to be described hereafter. 

It should be noted that many persons have, during limited 



MELANCHOLIA. 1 39 

and, indeed, quite prolonged periods, experiences of such 
depressive conditions and morbid beliefs, and that they do 
not affect their minds so profoundly as to prevent them from 
engaging in their usual occupations. Such persons not infre- 
quently consult the family physician who would not think 
of seeking the advice of an alienist. With or without 
special treatment the condition may pass away and again 
return after several weeks or months, and this process may 
recur several times before there shall become established a 
permanent or continued morbid state of mind ; and in many 
cases such a condition never ensues. 

Stupor. — The condition of stupor is so frequently found 
in cases of melancholia, that some authors enumerate a 
special variety, as "Melancholia with Stupor" ox" Melancholia 
Attonita." Its significance is so marked that its characters 
require a careful study. 

It should be noticed that this is a condition not confined 
to that genus of mental disorder we are now investigating, 
but one which may develop in the course of other forms 
of mental disease, or, according to Dagonet, as an inde- 
pendent disorder. It may arise in cases of violent maniacal 
excitement in which the nervous system becomes rapidly 
exhausted, and also from prolonged mental strain, especially 
in the young. 

Again, it may result in some degree from great prostra- 
tion of the nervous system in adults, and from a condition 
of anaemia ; from a long-continued abuse of the sexual 
organs, and from shocks to the moral faculties of the mind; 
in short, from the long continuance, or from the sudden 
and profound influence of any causes which tend to pro- 
duce an exhaustion of nerve energy, and thereby destroy 
the expectancy of hope and the power of anticipation. 

A young mother of a highly sensitive and nervous tern- 



I40 LECTURES ON MENTAL DISEASES. 

perament, after a protracted or instrumental labor, passes 
into a condition of violent excitement, which may continue 
during a few days, and then she may fall into a condition 
of stupor, which may continue for months. 

A young woman, who, perhaps, has never been a dozen 
miles from her father's house, is induced to emigrate to a 
foreign land, where she has been told it is easy to secure a 
living and lay up money. After arriving, she finds herself 
among strangers and helpless. She is unable to find em- 
ployment, and, perhaps, even to make her wishes under- 
stood. The disappointment is overwhelming ; she becomes 
sad and dejected, and soon falls into a condition of stupor, 
which remains indefinitely. 

In such cases there exists a short intermediate abnormal 
mental state, and, doubtless, a predisposition ; they are not 
common, and the condition of stupor is more generally 
associated with one of the stages of melancholia, of which 
it is the most conspicuous feature for the time being. 

It consists in a suspension, more or less complete, of the 
physical and mental faculties, and is, therefore, a greatly 
intensified form of the pre-existent apathetic condition 
which is a feature of melancholia. In some cases there is 
mental bewilderment combined with exaggerated inhibi- 
tion ; the emotional tone may or may not be of a painful 
character. The patient is in a condition which may be 
likened to that of a waking nightmare, in which the appre- 
hension of impending evil may be exceedingly intense, with 
entire lack of power to make any effort to escape. 

It does not usually develop without previous indications. 
The anxiety becomes less in degree, the hallucinations 
less vivid, and the false beliefs, which had made so powerful 
an impression and dominated the course of mental activi- 
ties and the forebodings, less absorbing. But these changes 



MELANCHOLIA. I4I 

are not attended by a return of the mind to channels of 
healthy activity. The character of the mental concepts does 
not become normal, only those of an abnormal character 
become less distinct and fade out ultimately. The mind 
appears to be void of ideas, or those present are in such a 
state of confusion and chaos that they are not represented 
in consciousness with sufficient distinctness to be appre- 
hended or remembered by the ego during any lengthened 
period. He is indifferent as to his relations to others and 
to his own personal appearance, so that his apparel is utterly 
neglected and is only used when it is placed upon him by 
others. 

His sense of shame and delicacy is lost, and the habit of 
cleanliness, which exercises so strong an influence when in 
a state of health, is now gone. The presence of danger, 
even, has little effect upon him, and cases are reported in 
which patients remain impassive when exposed to death 
by fire. 

This may be the effect of the delusion that they are 
unable to move, or that they are commanded not to move, 
and that if they do so they will be subject to punishment 
or injured by wild beasts. In short, some patients seem to 
be existing in an inner mental world — absorbed by their 
imaginations — and utterly unconscious of the world of 
reality with which they are surrounded, and of their 
friends who endeavor to minister to their requirements. In 
some cases the change is so great as to consist in a nearly 
total suspension of the emotional and intellectual faculties. 
The will also appears to be in abeyance when the condition 
of stupor becomes fully pronounced. It is to be understood 
that there may exist all degrees of this state, from that of 
merely an apparent indifference, to one so profound as to 
be mistaken for dementia. 



142 LECTURES ON MENTAL DISEASES. 

When this condition has become established, it is evident 
to the most superficial observer that a profound change has 
come over the state of the individual as evinced in his 
attitude and physiognomy. While the general lineaments 
and features of the face remain, yet the ordinary expression 
which gives more or less character to it, while in the con- 
dition of anxiety and depression, is entirely lost. The 
countenance is almost a blank, while the person remains 
wherever he is put, standing or sitting, during indefinite 
periods of time. In reality, movements are apparently 
attended with much discomfort, and the limbs will remain 
in most unusual and constrained positions without much 
nconvenience. The state of stupor, however, does not 
usually (though it sometimes does) reach that into which 
the cataleptic passes, and there is absence of all rigidity in 
the limbs and body. 

In other cases there may remain some faint impressions 
of such delusions and hallucinations as have previously 
dominated the mind ; the patient seeks to hide behind a 
chair or the sofa or under the bed, where he will remain 
until forcibly removed. He does not attempt to make his 
fears known to others except by the peculiar character of 
his conduct and the expression of his countenance. He 
will not speak or institute any kind of movement in conse- 
quence of anything addressed to him, except physical 
assistance or force. 

Some features of this condition maybe illustrated by the 
case of a young woman who has been under my care. Dur- 
ing several months it was impossible to induce her to speak, 
but she persisted, if left to herself, in remaining seated, or 
rather crouched, upon the floor, partly secluded in some 
corner of the hall or in her room, where she would remain 
for hours, if permitted to do so, in such a position as would 



MELANCHOLIA. I43 

be extremely painful to persons in ordinary health. She 
would not voluntarily take food or drink, and seemed to be 
frightened when it was offered to her. She was doubtless 
dominated by some impressions or voices which com- 
manded her not to take food ; or possibly by the delusion 
that the food contained poison ; or, again, by a hallucina- 
tion of sight by which there appeared to her some foreign 
substance or vermin in the food. She was largely insensi- 
ble to pain, and on one occasion, when carelessly placed by 
her attendant too near the radiator, put her hand upon it 
long enough to inflict a severe burn and subsequent 
sloughing of the tissues before the act was observed ; yet 
she did not indicate by word or movement any degree of 
suffering. 

This refusal of food is a very common and characteristic 
symptom while the patient is in the condition of stupor, and 
in many cases it results from some deeply seated delusion 
or hallucination of sight or hearing When this is the case, 
the patient will exhaust every effort in the endeavor to 
avoid swallowing the food. Other cases may experience 
no craving for food, or have any sense of hunger, and yet 
will swallow it without resistance when it is placed in the 
mouth. Patients have sometimes explained, after passing 
through the experience of stuporous states of mind and re- 
covering, that they were wholly dominated either by voices 
of persons or by the distressing delusion that they would 
experience the infliction of torments of various kinds, such 
as being roasted alive, or being scalped, or plunged in boil- 
ing water, if they should move in certain directions, or 
otherwise fail to comply with what is demanded of them. 

There can be little doubt that this mental lethargy is due 
to morbid changes which have taken place in the brain. 
This is evinced by the indications presented. For instance, 



144 LECTURES ON MENTAL DISEASES. 

in many cases the pupils are dilated and quite insensible to 
the presence of strong light. The sensory nerves are often 
as much affected as those of motion, and the anaesthetic 
condition extends over the whole body. The reflexes are 
absent ; the pulse is abnormally slow, and is not much 
affected by the use of alcohol or other stimulants when 
freely administered. The circulation of the extremities is 
imperfect, and in some cases the skin of the fingers and toes 
becomes blue. 

Injuries to these parts remain unhealed for weeks or 
months, notwithstanding all efforts to heal them. There is 
now a patient in the Retreat who has had a bruise upon 
the lower part of one leg which has remained an open sore 
for more than nine months. The temperature of the extremi- 
ties, and, indeed, of the whole system, is generally from one 
to two degrees lower than normal. In a case upon the 
male side of the Retreat the temperature has not been 
above ninety-seven and one-half degrees during the past 
three months, and often lower, which indicates how pro- 
foundly the general functions of the nervous system are 
compromised by the failure of nerve energy ; and when 
this extends to the pneumogastric nerve, food is not only 
unassimilated, but may remain in the stomach for hours and 
days undigested. In these cases patients must be sustained 
by the use of highly nutrient enemata. Dagonet says that 
ptyalism sometimes exists ; in my own experience only one 
such case has been observed. 

As already intimated, there appears to be some difference 
in the mental condition in cases of stupor. While some 
are entirely passive, and there is little appearance of any- 
thing beyond a vegetative kind of existence, others exhibit 
some degree of mental activity in the form of delusions. 
And even in the passive form there may suddenly occur 



MELANCHOLIA. 145 

changes which cannot be anticipated or accounted for, 
except upon the theory of changes in the circulation of the 
brain or modifications in the nervous discharges in the 
sensory centres. 

A patient may suddenly arouse from the lethargic con- 
dition and attack his attendant or another patient near by, 
exhibiting an amount of physical strength altogether greater 
than his condition would indicate. Another may institute 
an effort to kill himself or to kill others, and exhibit the 
greatest violence in his act ; or again, the change may be 
indicated by his beginning to converse, or showing a wil- 
lingness to take exercise, which may continue for a few 
hours, when he relapses into his former condition. In the 
latter cases such change may be regarded as a favorable 
indication, as it is very likely to recur again and again until 
convalescence is established. It is, however, important to 
bear in mind the fact that there exists a physical condi- 
tion which is common to both kinds of mental state, and 
which is the true basis of whatever kind of mental activity 
may present itself. 



LECTURE VII. 



MELANCHOLIA. (Concluded.) 

Melancholia with Excitement — Mental Pain and Anxiety — Fixed Delusions — 
Destructiveness — Self-infliction of Injury — Religious Type of Melan- 
cholia — Characteristics — Self-accusations — Homicidal Tendencies — Cases 
without Delusions — Sudden Changes in Mental States — Suicide — May 
Result from Hallucinations — Necessity of Great Watchfulness in Refer- 
ence to all Persons Affected with Melancholia — Medico-legal Aspect of 
Suicide — An Attempt to Commit Suicide not Necessarily a Proof of In- 
sanity — Some Experiences are More Terrible than Loss of Life and Destroy 
any Desire for It — Prognosis — Patients May Recover after the Disease has 
Existed for Several Years — Cases — Treatment — Importance of Removing 
the Exciting Cause — Change of Scene — Physical Conditions — Abundance 
of Easily Digested Food — Sleep — The Use of Opium — Artificial Feeding 
by Stomach or Nasal Tubes — Importance of an Early Use of the Tube 
when Patients Refuse to Eat — Melancholia as a Symptom in Other Forms 
of Mental Disease. 

There are other cases of melancholia, sufficient in num- 
ber to form a class by themselves — Melancholia with 
Excitement — which present symptoms quite the opposite 
of those of stupor. A state of intense restlessness pre- 
dominates, and patients are unable to remain quiet for a 
moment. This feature is quite as marked and as characteris- 
tic of them as that of stupor or lethargy is of the former 
class. The mental pain, anxiety, and sadness, united with 
the dominant influence of deep-seated delusions, seems to 
impel them to be constantly on the move. The sphere of 
motor activity is frequently limited, and the patient, if left 

146 



MELANCHOLIA. 1 47 

to himself, instead of taking long walks in the open air, or 
of walking with any definite purpose whatever in mind, 
spends his time in tracing and retracing his steps from one 
side of the hall to the other in the same line. This will be 
continued for hours, and even for days, or until the limit of 
endurance is reached and he becomes exhausted. 

Others rush about in the most aimless manner, wringing 
their hands and repeating over and over some words of 
regret, and it is as difficult to secure their attention as it is in 
cases of acute mania. Indeed, patients in this form of melan- 
cholia approach more nearly to the condition which charac- 
terizes acute or delirious mania, so far as relates to motor 
excitement. Again, they try to injure themselves in every 
possible way, by beating the head against the wall or the 
furniture, or falling on the floor, or throwing themselves 
down the stairway, screaming in a wild, incoherent manner, 
under the influence of some horrible delusion. They may 
endeavor to gouge out their eyes, pull out their hair, hack 
at their throats, or destroy the sexual organs with anything 
they chance to lay their hands upon. In such cases the 
field of consciousness is filled with horrible illusions and 
consequent delusions as to its present condition and envir- 
onment, and with fearful forebodings as to what is about to 
be experienced, and from which the patient seeks to escape. 

Such a condition is the source of endless anxiety as long 
as it may continue, but there is actually much less ex- 
penditure of nerve force in the same period of time than 
occurs in delirious mania, or than would be anticipated 
from the restlessness and apparent suffering, and if patients 
can be tided over it, and the useless, misdirected motor 
force is allowed to expend itself in the open air while self- 
infliction of injury is prevented, there is a fair prospect of 
recovery. They do not usually pass into a condition of 



I48 LECTURES ON MENTAL DISEASES. 

stupor or dementia, but, on the contrary, regain the full use 
of the mental faculties when recovery is established. 
Such cases doubtless result from the invasion of disease to 
the ideo-motor centres of the brain. The following case 
exemplifies the intensity of delusions in such cases and also 
some of the measures which may be adopted to consum- 
mate the suicidal purpose. 

S. S., aged thirty, married, has five children, the youngest 
five months old. Husband has been without work for 
several months and the family without sufficient food. The 
disease developed rather suddenly, and there had been no 
previous attack. The report is that she became violent 
and attempted to injure one of her children, broke articles 
of furniture in the house, and then was removed to the 
town-house. After a few days she passed into a state of 
frenzy, imagined that she was pursued by devils ; twice 
attempted suicide while there. In the first attempt she 
endeavored to dash her brains out against the wall of her 
room ; in the second she tried to burn herself. She seized 
hold of a hot steam-pipe and burnt the palms of her hands 
so that the flesh hung in shreds ; her head was also badly 
burned, and her face and head covered with contused 
wounds and bruises. She had no recollection afterward of 
her attempts to injure herself, and when asked about them 
could give no explanation. After her removal to the 
hospital she seemed to be more quiet, but greatly depressed 
and suspicious of those about her; refused her food, as she 
said it was poisoned. Nine days after admission, while 
apparently in a state of great depression, and while sitting 
with other patients, she suddenly started up and exclaimed 
that the devils were after her, dashed her head against the 
wall, tore the bandages from her face and hands, and was 
restrained from executing her attempt with much difficulty. 



MELANCHOLIA. 1 49 

There exists still another class which presents a character 
peculiar to itself, and which requires some attention. In 
this class the form of delusion and the general character of 
nearly all the concepts which occupy the field of conscious 
activity take on a religious type. Religious beliefs them- 
selves are rarely the cause of insanity, even indirectly, 
unless they become extravagant or perverted in character. 
On the contrary, nearly all the forms of religious belief in 
Christian, and even in other countries, are a source of solace 
and comfort to those holding them, in the ordinary or in 
the extraordinary experiences of life. But when the brain 
passes into the super-sensitive condition of melancholia 
and all impressions become greatly exaggerated in their 
effect upon it, and the course of thought for any cause 
tends toward a religious obligation and belief, especially if 
the mind has in its past history been profoundly influenced 
by this subject, it not unfrequently absorbs the whole circle 
of mental activities. The general mental and physical 
condition of the patient is that of melancholia, only the 
•subject matter of thought pertains largely to the past 
experience in reference to religious beliefs, which become 
perverted and changed into a source of great misery. The 
patients are constantly accusing and reproaching them- 
selves for what they have done or failed to do ; for what 
they have said or failed to say to others on the subject of 
religion ; for the wicked motives which have been actuating 
them all their lives, even in the performance of their most 
sacred duties. They accuse themselves of secret practices 
and faults of which there has never existed in their past 
lives the slightest evidence. Women sometimes declare 
that they have been false to their marriage vows and 
obligations, at least in their inmost thoughts, and otherwise 



150 LECTURES ON MENTAL DISEASES. 

abominably wicked. They have had sexual intercourse 
with the devil, are possessed by him, and are full of all 
manner of uncleanness, when there has never been a 
shadow of reproach against them. Indeed, the more pure 
and exalted has been their antecedent character, the more 
likely are such persons to exaggerate statements as to 
their wickedness and perversity of character toward God 
in their disordered condition. 

They are also constantly in fear lest they are about to be 
punished for their delinquencies. They regard themselves 
as objects of scorn to their fellow- men, and, therefore, they 
must be much more so in the eyes of the Supreme Being, 
and in consequence are in danger of eternal punishment. 
Such views are expressed more often by women than by 
men, and, I think, by those in whose early religious train- 
ing the idea of punishment was made prominent. The 
parental relation of the Supreme Being toward all mankind 
was rarely alluded to, while the attributes of justice and 
power were constantly dwelt upon. In children having 
impressible and sensitive nervous systems, such instruction 
often makes a much more profound and long-continued 
impression than those imparting it imagine or desire to 
produce. In fact, the effects never wholly pass away from 
the brain in some cases, and when the system becomes 
unusually sensitive, partially anaemic, and in such a condi- 
tion that all subjective and objective impressions are greatly 
exaggerated and persistent, then it is that these old impres- 
sions which have, perhaps, lain dormant for years, or have 
been but dimly remembered, awake into vigorous life again 
and hold sway over the currents of thought. In some of 
these cases there exists a greatly perverted state of moral 
sensibility, which leads to the necessity of extreme care ; 



MELANCHOLIA. I 5 I 

they become, at times, dangerous to everybody who may 
have anything to do with them, as well as to themselves ; 
they are both homicidal and suicidal. 

Finally, cases of melancholia sometimes come under 
the observation and care of the physician in which no 
delusions are manifest, and it is quite impossible to discover 
any lesion of the intellectual faculties. The person is quite 
clear in his perceptions as to his relations with others and 
his own affairs, but the moral sensibility appears to be nil. 
He has become utterly negligent, careless, and quite insen- 
sible to any appeals which may be made to him by others ; 
he appears to have no will-power ; is apathetic, and entirely 
heedless concerning his dress and personal appearance. 
Persons who have been the most punctilious and precise 
in the observance of the amenities and conventionalities of 
society and have been very fond of being much in society, 
pass into a mental condition that is quite the reverse of 
what has before existed. 

An interesting feature of these cases is that they are 
thoroughly conscious of the change which has occurred ; 
may even greatly regret it, and become sad because of it ; 
reason about the change and the present state clearly 
enough, and explain it to others, but at the same time 
declare that they are utterly helpless to make any effort to 
remedy the difficulty ; it is altogether impossible for them 
to again take up their former habits of thought or physical 
activity. 

The general physical symptoms which exist in the milder 
forms of melancholia are present. There is a semi-paralysis 
of the motor nerves, or of the motor areas of the cortex, 
and all movement is unpleasant and requires external aid 
for its accomplishment. 

There exists a tendency in some of these cases to quickly 



152 LECTURES ON MENTAL DISEASES. 

become profoundly sad and depressed, and it is then but a 
step forward when they pass into a mental state in which 
the thoughts become vague and confused and the physical 
sensibility greatly lessened. The sequelae of this change 
are generally some forms of physical disease. The organs 
of assimilation become impaired, the digestion faulty, the 
circulation feeble, and, within a limited period, some form 
of organic disease appears, the precise nature of which it 
may not be easy to determine. 

Suicide. — Another of the very important conditions 
which is present in a considerably large per cent, of cases 
is an indifference as to living, or a positive desire to die. 
The usual zest of existence which pertains to all forms of 
animal life, and is one of the deepest and most permanent 
of the instincts, is in abeyance, and the patient experiences 
no pleasure in life. In the milder and less pronounced 
forms of the disease this indifference may remain simply 
an indifference, while in other more serious cases persons 
will express a desire and even a longing for death, but fear 
to die. They have no right to life, and are too worthless 
to live, and would not longer live, — 

" But that the dread of something after death — 
The undiscovered country, from whose bourn 
No traveler returns — puzzles the will, 
And makes them rather bear those ills they have, 
Than fly to others that they know not of." 

But in a certain proportion of the more grave forms of 
the disorder, the mental pain overmasters all fear or dread 
respecting the future and all other considerations, and impels 
the unhappy patient forward to every effort to execute his 
suicidal impulse. Suicidal tendencies may exist in other 
forms of insanity, but they generally arise from a spirit of 
recklessness or an absolute dethronement of reason, rather 



MELANCHOLIA. 153 

than from any definite or fixed purpose. In melancholia, 
however, the patient broods over the purpose until it 
becomes " a sweet morsel " to his imagination, and no effort 
is left untried to accomplish his morbid purpose. 

Not unfrequently patients are impelled to make suicidal 
attempts by the influence of hallucinations and delusions. 
They hear voices from heaven at times commanding them 
to drown or hang themselves. Some feasible method of 
accomplishing the deed is suggested to the mind by seeing 
an instrument by means of which it could be done. 
Thought is arrested and lingers upon it; the purpose 
begins to be formed, when suddenly a voice is heard 
in the form of a command which hastens the effort 
to accomplish the design. In other cases still, persons 
believe that they are being pursued by their enemies or by 
officers of the law in order that they may be publicly 
disgraced, or executed in some ignominious manner, and 
to avoid this they try to end the scene and trial of life. 
Hence, the importance of the utmost watchfulness in the 
care of all persons in whom such indications have been 
exhibited, as the purpose may be executed in a very simple 
manner. Such cases are frequently met with outside of 
asylums, and the reports of them are spread on the pages 
of the daily newspapers. 

It should not be understood that those persons who 
speak freely of suicide to others are those most likely to 
commit the act. It is rather the reverse of this, and those 
who threaten the most are really in less danger of effecting 
their purpose than some others are who never divulge the 
existence of the inclination. There are others still, who make 
but an abortive attempt ; they use some knife or scissors 
so dull that it is evidently impossible to do much execution ; 
or they try a cord so small that it is sure to break before 

T4. 



154 LECTURES ON MENTAL DISEASES. 

they are harmed. In the progress of the disorder, however, 
the half-formed purpose may harden into a deep and per- 
sistent resolve. Hanging and drowning are the methods 
most frequently adopted, while shooting, poisoning, and 
cutting come next in point of frequency. 

The subject of suicide sometimes becomes important in 
a medico-legal point of view. The question is not un- 
frequently raised as to whether suicide is not always an 
evidence of insanity, and of itself enough to prove that 
the person seriously attempting to commit such an act was 
insane. This view is advocated by some on the ground 
that the love of life is so innate and powerful an instinct, 
in at least all the higher forms of animal existence, that it 
leads its possessor to endure all forms and degrees of pain, 
and to make the most strenuous efforts, rather than sacri- 
fice it. 

While suicidal attempts are generally the result of de- 
rangement of mind in this country, it is safe to conclude 
that generalizations as to what sane persons will or will 
not do, under almost any conditions of life, are of doubtful 
utility and may lead us far astray. It is difficult to assert 
what any special act, by itself, may indicate as to sanity or 
insanity. The act of suicide, as, indeed, almost all other 
courses of conduct, will be found to be regarded very 
differently even among persons living in the same country 
and educated under the same general civil conditions. 
Much more will it be the case when persons have been 
educated under the influence of systems of civilization 
which widely differ. For instance, a woman in India who 
has lost her husband, formerly, and possibly now, entertains 
the belief that it is her duty to commit suicide. The 
Russian officer who feels that he has been insulted by his 
sovereign, or by one from whom he is forbidden to seek 



MELANCHOLIA. I 5 5 

an apology, commits suicide, having been educated to 
regard this as the proper course to pursue under the 
circumstances in which he finds himself. Honor and 
self-respect are more precious than life itself. In certain 
countries and certain sections of this country, at the present 
time, persons believe that when insulted the only thing to 
do is to kill the obnoxious person or be killed by him, or, 
at least, place themselves in the way of such results. 
Personal honor is the first consideration with them, and 
the love of life is relegated to a secondary position. 

Now it would seem far more probable that the ever- 
changing conditions and experiences which surround many 
persons — such as grief and disappointment, losses of friends 
and property, the betrayal of friends, suffering from physical 
and mental pain with no prospect of relief, remorse for 
wrong done, seduction and abandonment, helplessness and 
poverty, dread of public scorn for crime committed — in 
short, many conditions of life, may be so repugnant 
and horrible, and cause such keen mental sufferings to 
persons, as to destroy the love of life and lead intelligently 
to the choice of death more certainly than such circum- 
stances and conditions of life as related above. And if we 
add, further, the belief that there is no hereafter, that this 
life ends all, and death means only peace and eternal 
oblivion, we can easily understand how many persons may 
long for it so earnestly as even joyfully to take the fatal 
step, with no dethronement of reason. The frequency of 
such occurrences will depend largely upon religious beliefs, 
educational influences, and the general civil conditions 
amid which society exists. Therefore, in determining the 
bearing of an attempt at suicide in its relation to mental 
soundness, other evidence as to the mental state than the 
act itself should always be sought for. 



I56 LECTURES ON MENTAL DISEASES. 

The prognosis, in cases of melancholia, is generally 
favorable when the disease has developed rapidly, and is not 
accompanied by any organic disease. In those cases in 
which the advent has been slow, or extended over years, 
with marked intermissions, it is less favorable. When it 
depends upon any lesion of the brain, whether attended or 
not with convulsive attacks, the prognosis would be, as in 
other forms of mental disorder dependent upon such a cause, 
unfavorable. When it arises in consequence of disease of 
other organs of the general system, the prognosis will de- 
pend upon the character of such lesions. In cases where a 
state of mental lethargy has existed a long tirrie, and 
recovery ensues, the preceding physical changes are 
gradual ; the normal sensation of the body becomes again 
established ; voluntary motion becomes more frequent ; the 
appetite returns, and food is digested and assimilated ; nu- 
trition is more perfect, and flesh increases. In proportion 
as these physical changes occur, the mind returns to its 
channels of normal activity. 

Patients may die from the supervention of some acute 
or local disease affecting any of the organs of the body, 
such as dysentery or carbuncle, etc. The patient has 
little resistive power and speedily succumbs to the develop- 
ment of morbid conditions of the general system, which, 
in a state of mental health would have very little effect. 

There is one peculiarity which is often observed, 
and, indeed, is nearly always present during the progress 
of recovery in simple melancholia, which is, that the 
patient is rarely or never willing to admit that he is 
better, or that there is any prospect of ultimate recovery. 
On the contrary, he is always prophesying that he will 
never recover. But when once his health has become 
established, he does not hesitate to speak freely of his 



MELANCHOLIA. 1 5/ 

experience of ill health, nor does he exhibit any such 
sensitiveness about it as is generally found in persons who 
have recovered from other forms of mental disorders. 

Patients with melancholia more often recover, after the 
disease has existed during a long period, than those with 
other forms of mental disease. A case was under the care 
of Dr. W. H. Buel, of Litchfield, Conn., during several 
years, and was not known to have spoken a word for twelve 
years, yet he finally made a good recovery, and again 
entered into large business relations. A patient was dis- 
charged from the Retreat in 1882 as recovered who had 
been ill between four and five years, and has since remained 
in good health. 

There was a case in the Retreat, admitted in 1873, 
which illustrates the importance of continued expecta- 
tion of recovery even after a long period of profound 
mental inactivity and melancholic stupor. It was in a 
woman thirty-six years of age, who was under treatment 
between two and three years, and had been in a condition 
of melancholia for nearly a year prior to admission. Dur- 
ing two years and three months she rarely spoke or opened 
her eyes. She did not, voluntarily, take one step, and 
passed each day lying on the sofa, to which she was car- 
ried or assisted every morning from her bed, except when 
carried out-of-doors to remain for a sun-bath. She appar- 
ently suffered little bodily pain, and slept well at night. 
She was regularly fed with a stomach tube three, and a 
part of the time four, times a day after her admission for 
two years and three months, and never could be persuaded, 
by any means, to take either food or drink in the ordinary 
manner. During the last few months there were indications 
of a partial paralysis of the left side of the body ; she could, 



I58 LECTURES ON MENTAL DISEASES. 

however, move both the arm and the leg, though in a less 
degree than those on the right side. 

She was always cleanly in her habits, and signified her 
wants by a peculiar moaning sound. Her case certainly 
appeared unpromising, both from the length of time it had 
continued, and the evidence that nervous centres were 
organically affected. At this time it was decided to use 
other measures with the view of stimulating the central 
nervous system into greater activity. This consisted in the 
daily application of ice directly to the spine over the fourth, 
fifth, sixth, seventh, and eighth vertebrae, and the ice was 
held in position during ten or twelve minutes for ten days. 
After some six or seven days the attendant reported that 
the patient was beginning to give some indications of in- 
creased mental activity. At the expiration of twelve days 
she was exhibiting unmistakable indications of improve- 
ment as evinced by making requests, replying to questions, 
opening her eyes and noticing persons when they were 
speaking to her. The application of ice was omitted for 
several days and again used with indications of more marked 
improvement than before. This treatment was continued 
for five or six weeks with daily indications of increased 
intelligence and interest in those about her and what was 
done for her. She began to eat solid food when it was put 
into her mouth, and at the end of seven weeks fed herself. 
She conversed freely and intelligently from that time, read 
the papers, and became anxious about her children and 
friends. She said that she had very little remembrance of 
what had occurred since she came to the Retreat, that 
nearly all was a blank, but that she remembered occur- 
rences prior to her stupor. She soon became anxious to 
regain the power of walking, and began to try with the aid 



MELANCHOLIA. 1 59 

of an attendant. At the end of ten weeks she had so far 
recovered that she was dressed regularly, remained up all 
day, ate well, talked cheerfully with the attendants and 
friends, and was looking forward with much anticipation to 
going home. 

At this time she was visited by her husband and 
youngest child, conversed with them freely, and seemed 
in remarkable spirits, and when she bade them good-bye 
said that she should be ready to go home whenever her 
husband should come for her. Two days later, she arose 
in the morning and dressed as usual, expecting to return 
home, and walked to the window to look out. She was 
suddenly seized with an apoplectic attack and died in thirty 
minutes. The excitement of anticipation, acting upon the 
abnormally sensitive condition of the brain tissue, was too 
great, and caused it to give way ; or the emotional excite- 
ment might act indirectly upon the brain by causing 
increased action of the heart, thus producing a rupture of the 
coats of some vessel in the brain. The case illustrates what 
may sometimes occur even in the most unpromising cases. 

It is not easy to predict what cases will or will not recover, 
except when there are decided indications of organic change 
in the brain. A long continuance of untidy habits, a 
failure of the system to respond to the administration of 
nourishment, and a state long continued with fixed ideas 
as to persecution, are of unfavorable significance. Age is 
also an important factor as to the prognosis. Young per- 
sons are much more likely to recover than old ones ; 
indeed, recoveries among patients who are past sixty-eight 
or seventy are very rare. 

Treatment. — In melancholia treatment both by medica- 
tion and management is of the first importance, especially 
in the initiatory stages. First, endeavor should be made to 



l6o LECTURES ON MENTAL DISEASES. 

remove as fully as possible the exciting cause or causes, by- 
means of a change in the daily surrounding and avocations. 
For this purpose travel and visits to places before unvisited 
will be of the highest service. Still, the change should not 
be too radical, and persons should not be too far removed 
from home and friends, or to countries where the customs 
and habits of life are too greatly at variance with those to 
which they have been accustomed. The experiences and 
fatigues incident to travel in a foreign country should be 
avoided, except in such cases as have formerly experienced 
them and have already acquired a taste for them. Seek 
for such changes as will arouse the curiosity and excite 
the interest, and thus turn the mind into new channels of 
thought and purpose. 

A traveling companion who can tell a good story, is not 
easily excited or discouraged, and is always looking on the 
bright side of experiences, is the desideratum when the 
initial period has passed. 

When the disorder has become pronounced, it is especi- 
ally desirable to remove the patient from the society of his 
friends and family, and in nearly all cases to an asylum for 
special care, change, and treatment. Such a course should 
be taken as a precaution against suicide, as well as to 
ensure the most efficient means of treatment. The exhibi- 
tion of a deep interest in the improvement of patients, and 
the manifestation of sympathy and friendly feelings, are 
often of service, especially during the period of convales- 
cence, and appear oftentimes to be more effectual than any 
other means to rouse the patient to make an effort toward 
aiding himself in recovering a state of hopefulness. The 
moral treatment of all forms of insanity is of the first 
importance, and especially is this the case in simple 
melancholia. It is very certain to accomplish more in the 



MELANCHOLIA. l6l 

majority of cases than can be done by the administration 
of drugs. In proportion as patients can be induced to 
engage in games, or visit places of amusement, and, still 
better, to occupy themselves in some form of light work 
and to be much in the open air, may favorable results 
be anticipated. 

Second. — Seek to restore to normal activity any of the 
secretory organs which may be deranged. This may be 
attempted by means of saline laxatives, mineral waters, 
prolonged warm baths, laxative food in abundance, the use 
of fruits, and stomachic tonics in the form of dilute muriatic 
acid and quinine. Food should be taken several times 
daily, and such as is of highly nutritious character. Active 
purgative medicines and so-called cholagogues should be 
avoided, and, if necessary, movements of the bowels should 
be secured by means of injections. Remedies for this 
purpose should be addressed toward the removal of the 
primary cause, which, in the majority of fully developed 
cases, is exceedingly difficult to effect. 

Third. — Endeavor to secure several hours of sleep every 
night. Changes of scene will aid in doing this and, if the 
patient is able, a large amount of gentle exercise should be 
taken in the open air daily by walking. By such patients 
as have been accustomed to sedentary habits of life, several 
hours spent in riding, or in some form of moderate exercise, 
will indirectly conduce toward this object from its influence 
upon the circulation. In some cases whisky diluted with 
water may be of service, and in all cases the bromides 
hold high rank as efficient agents. Opium, in the form of 
Squibb's deodori^d tincture, may be combined with the 
bromides with much advantage at times and for short 
periods. 

There are some cases which may be greatly benefited by 



1 62 LECTURES ON MENTAL DISEASES. 

the regular and systematic use of opium, administered in 
from twenty to sixty minims of Squibb's deodorized tincture 
three times a day. It appears to partially anaesthetize the 
supersensitiveness of the brain, and thus relieves the mental 
pain. It probably also exercises an influence upon the 
vaso-motor system of nerves, and thus indirectly increases 
the circulation. Opium may be used for weeks in this way, 
thus greatly relieving the suffering of the patient without 
disturbing the organs of digestion. As recovery advances 
it may be gradually diminished and abandoned without 
future inconvenience to the patient and with little or no 
danger of establishing the opium habit in the system. 

The systematic and regular administration of food is of 
the first importance in melancholia. The patient will 
declare that he has already taken too much food, that it 
only causes irritation in his stomach and bowels, etc., etc., 
to all of which no attention is to be paid. A large amount 
of farinaceous and easily digested food must be taken 
during each twenty-four hours. It is better to take it in 
divided doses, so as at no time to overload the stomach. 
The tendency is to lose flesh and become emaciated ; the 
nerve-centres are imperfectly nourished and consequently 
have an insufficiency of energy ; hence, when the patient 
once begins to increase in adipose tissue, it is a most 
favorable indication, and one looking toward recovery. 
When the digestion is not good, broths, soups, with milk 
and eggs, may be given with ale, together with fish and 
easily digested meats. 

Artificial Feeding. — As patients affected with melan- 
cholia, more often than others, requfte to have food 
introduced into the system by artificial means, it may be 
appropriate to refer to the subject at this time. The 
refusal to take food may arise from different causes in 



MELANCHOLIA. 163 

different cases ; in some, from the delusion that all food 
offered or provided for them is poisoned; in others, from 
the presence of hallucinations of hearing ; they think voices 
are heard commanding them not to eat, and that serious 
results will follow if they do ; others imagine that they 
perceive things in the food which render it unfit to eat. 
The refusal of food may also arise from indifference to life, 
and from the fact that patients experience no craving for 
it, etc. 

It is important to ascertain, if possible, for what reason 
food is refused, especially in patients recently received in 
an institution, and if it be from a general suspicion of those 
immediately about them, it will be well not to insist at once 
upon the patient's eating. It will be better to gain the 
confidence of the patient and allow him to follow his own 
inclination in the matter for awhile. Food of a tempting 
character may be left in the room, and opportunity afforded 
to eat when there is no one about to observe. In some 
cases such a course will prove best; suspicions will be 
allayed and a sufficient quantity will be used. 

In other cases it will be necessary to introduce food to 
the stomach against the wish and earnest protest of the 
patient. This is usually done in one of two methods — 
that is, by either a strong though flexible gutta-percha 
tube introduced through the mouth to the stomach, or by 
a soft and very flexible rubber tube introduced to the 
stomach through one of the nostrils. In some persons 
the muscular tissue and the soft parts immediately about 
the fauces are very sensitive to the presence of any unusual 
foreign substance, especially if it is hard. The stomach 
tube may, therefore, cause very strong contractions of 
these parts, and it will generally be better to use the nasal 
tube in such cases. Indeed, I have, for many years, been 



164 LECTURES ON MENTAL DISEASES. 

in the habit of using it in nearly all cases, as it appears to 
occasion less annoyance. It also avoids the necessity of 
using force to open the jaws by means of some kind of 
wedge or lever, as these are generally held very firmly 
together. There, however, exists, probably, a little more 
danger of the nasal tube passing into the larynx from the 
posterior nares than of the large and less flexible tube 
usually used for passing through the mouth ; but, with 
requisite care, this very rarely happens, and the use of the 
nasal passage produces less irritation in most cases. 

The food intended to be introduced into the stomach,which 
may consist of beef tea, beef extract, milk, or milk and 
eggs, with such medicines and stimulants as may be desir- 
able, should be placed in a bottle designed for the purpose 
and made ready for use before the introduction of the tube. 
This being in readiness, and the tube being introduced, its 
free end should be pressed over a small nozzle which 
protrudes from one side of the bottle very near its lower 
margin. The bottle is then raised, and the contents at 
once pass into the stomach. This method is much more 
easy of execution, and more satisfactory in my experience, 
than the use of a pump and a stomach tube. 

In some cases the irritation caused by the presence of 
the tube at or near the cardiac orifice of the stomach 
causes emesis, and what has been introduced is immedi- 
ately rejected. In other cases the stomach does not digest 
the food introduced, and after a longer or a shorter period 
it is vomited. Under such circumstances the system may 
be supported for days, and even weeks, by the use of 
nutrient enemata, introduced to the rectum every four or 
five hours. I recall instances in which the life of the 
patient has undoubtedly been saved by this means. It may 
also be better for some persons who are very sensitively 



MELANCHOLIA. 165 

organized and easily frightened ; also in cases of females 
during the first few days after admission to the asylum, as 
the enemata may be administered by the attendant or the 
supervisor. 

The importance of avoiding a too long delay in resorting 
to some method of artificial feeding when food has been 
refused can hardly be overstated. In nearly all such cases 
the patient has taken a scanty amount of food for a long 
time before it has been utterly refused. 

Dr. Todd, the first superintendent of the Retreat, was 
accustomed to use iron very freely in the treatment of 
melancholia. He compounded a special preparation, and 
it has since been known as Todd's Mixture. I have failed 
to derive much benefit from its use, or that of any other 
preparation of the drug in this form of disease, and now 
rarely use it. On the contrary, I use strychnine, hypo- 
phosphites, arsenic, and, I believe, often with benefit. 

It is important to bear in mind that melancholia, as a 
symptom, may be present in other forms of mental disease, 
for instance, in epilepsy, general paresis, senile insanity, 
and in one of the stages of folic circulaire. This symptom 
being the most prominent one in the form of insanity 
described above, properly determines its nomenclature. 



LECTURE VIII. 



MANIA. 



No Invariable Standard of Mental Activity — The Frequent Changes in the 
Physical System — Epochs of Life — Inhibitory Centres First Affected — 
Delirium — Definition — Etiology — Profound Moral Impressions — Insta- 
bility of Brain Structure — Mode of Invasion — Preceded by Feelings of 
Lassitude and Depression — In some Cases, however, the Disorder An- 
nounces Itself by Marked Excitement — Physical Symptoms — Contrast 
Between those of Mania and Melancholia — The Physiognomy — Pupils — 
Increase of Motor Activity — Tongue — Physical Strength — Anaesthesia — 
Insensible to Fatigue — Increased Flow of Blood to the Brain — Increase 
of Appetite — Excitement of Sexual Centres — Catamenia— Insomnia — 
Sensorial Derangements — Hyperesthesia — Hallucinations — Illusions — 
Mental Symptoms — Memory Quickened — Rapidity of Speech — Conduct 
is Mainly Impulsive, or of an Instinctive Nature — Element in Thought — 
Change in Character as Evinced in Conduct of Business and in Home- 
Life — Importance of Knowing the Full History of such Cases in Forming 
a Diagnosis — Convalescence. 

As the term melancholia has been used from time 
immemorial as a synonym for sadness, dullness, and di- 
minished mental activity, so, in like manner, has mania been 
used as a synonym for continued hilarity, excitement, and 
increased mental function in any special direction. Both 
depression and excitement may, and often do, exist without 
any morbid basis and while the brain is in a condition of 
health. There can be no unvarying standard of activity in 
mental operations. Every individual may be said to be, in 
this respect, a law unto himself and limited by the constitu- 
tion of his central nervous system. A degree and a 

1 66 



MANIA. 167 

continuance of excitement which might rightly be regarded 
as abnormal in one person, would not be necessarily so 
regarded in another. There exist wide departures in these 
respects, at times, in every person, in either direction. The 
ever-varying conditions of the physical system have a large 
influence upon the brain, not only in respect to the amount 
of its function, but also in respect to its quality and its 
facility of action. Concentration of attention, continuity 
and perspicacity of thought, are greatly more difficult, and 
often retarded when certain bodily conditions of health 
exist, as compared with certain others in the same person. 
Different periods of life also greatly modify the character 
and quality of brain activities, especially in the female. 
There also exists a very wide range of difference in this 
respect among different nationalities. While, then, such 
changes in the ordinary conditions of mental activities are 
the first indications usually observed in cases of melan- 
cholia and mania, yet they are of little importance when 
considered by themselves, as other elements of change are 
always found to accompany them. 

Having studied in the preceding lecture the morbid 
states of mind termed melancholia, with its large variety 
of departures from a normal standard, all of which represent 
conditions of depression combined with painful emotions 
and a self-consciousness which has become abnormal in 
character, united with an aversion toward, and even an 
incapacity for, physical exertion, we now turn toward its 
opposite — viz., mania. In this disorder the inhibitory 
centres are the first to become affected, and there exists an 
unusual freedom of action which manifests itself in the 
affective faculties rather than in the intellectual. The im- 
pulses become stronger and are less easily restrained, until 
there is established a more or less continuous excitement, 



1 68 LECTURES ON MENTAL DISEASES. 

attended with an exaggerated self-confidence and an 
unusual energy of will. 

The essential primary element, therefore, in maniacal 
conditions of the mind consists of some lesion of the 
emotional department of the brain which results in an 
increased quantity of psychical activity, and in a derange- 
ment and confusion of thought, attended at times with 
delusions and hallucinations, together with an increase of 
muscular activities of various kinds. Whether the develop- 
ment of the maniacal state is the result of an extension of 
the morbid condition of the brain which nearly always 
precedes it, i. e., that of depression ; or whether it be due to 
changes of another character, de novo in the brain ; or, 
again, to the invasion of additional nerve-centres, is not 
easy to be determined. The latter view is more probably 
the correct one. 

It is important to bear in mind that such increase of 
mental action and restless motor activity are not confined 
to cases of acute mania. A derangement of emotional 
energy, similar to that which arises from the presence of 
delusions and hallucinations, is sometimes present in cases 
in which there exists a profound failure of the mental 
faculties. The same is true, at times, in acute inflammation 
of the meninges of the brain in delirium tremens and in 
typhoid fever. 

Definition. — Mania may be defined as consisting in a 
morbid excitement of the affective faculties, which discloses 
itself not only in a prolonged increase of psychical functions, 
but also in increased muscular activities, impairment of 
judgment and self-control, with change of character. 

./Etiology. — Profound moral impressions, physical ill 
health, reverses in fortune, loss of property, disappointment 
in love, seduction and abandonment, and, in short, such 



MANIA. 169 

experiences as deeply affect the emotional faculties of the 
mind. In the large majority of cases however, there exists 
back of these exciting causes the predisposing one, viz., an 
unstable constitution of brain structure, which may have 
been inherited from parents or grandparents, or may have 
been the result of former ill-health, or the practice of vicious 
habits of life. 

Mode of Invasion. — In the large majority of cases the 
condition of maniacal excitement is preceded by one of 
depression. It is afterward remembered that during sev- 
eral weeks or months, the patient has exhibited a change 
in his feelings and character; his likes and dislikes ; has 
been moody and fitful, irritable, has not slept well, and has 
complained that something was wrong. This is gradually 
succeeded by nervousness, restlessness, discontent, talking 
to himself, and in some cases by hallucinations of hearing. 
Those who have passed through one or more attacks of 
mania, generally recognize these indications, and not un- 
frequently declare the belief that they are again to become 
insane. 

According to some authors, some such incubative stage of 
melancholia (stadium melancholicum) nearly always pre- 
cedes the development of mania, and may come to be re- 
garded as constituting a part of the symptoms. But there 
can be no doubt that the disorder arises in some cases with 
no antecedent conditions of depression sufficiently well 
marked to have attracted the attention of friends or physi- 
cians. It may arise in this manner from sudden fear, moral 
injury, excess in the use of alcohol, and from the prac- 
tice of venery. It announces itself at once by marked 
physical and mental excitement. In such cases there may 
have been some pain in the head, and inability to sleep as 
much as usual. The latter symptom is one of the most 



I70 LECTURES ON MENTAL DISEASES. 

persistent, and generally one of the last to disappear. Some- 
times cases are ushered in by a stage of more or less febrile 
excitement, with loss of appetite, loathing of food, and in- 
crease of temperature, unpleasant dreams, loss of flesh, con- 
stipation, and abnormal sensations, etc. These conditions, 
however, pass away as the disease declares itself, and the 
patient becomes abnormally insensible to his surroundings 
and experiences. 

Physical Symptoms. — The contrast between the physi- 
cal conditions present in mania and those existing in mel- 
ancholia is certainly most marked, and when the disorder 
has become fully pronounced, becomes especially appa- 
rent in the countenance and the whole bearing of the patient. 
The physiognomy, instead of being pinched and thinner 
than in health, becomes fuller; the capillary circulation is 
increased ; the eyes become brighter, more expressive, have 
an increased freedom of movement, and, at times, under the 
influence of excitement, are protruding ; the pupils are, in 
some cases, contracted, and in others dilated, and, in the 
same case may vary from day to day, and even from one 
part of a day to another ; they appear to be more sensitive 
to the presence of light than in health, especially in the 
early period of the disease. The body becomes more erect 
and assertive when walking or standing, the patient becomes 
careless as to personal appearance, and the dress is dis- 
ordered ; the hair unbrushed, and, in some cases, dry and 
stiff; the voice is pitched in a higher key, and the words 
flow rapidly and freely, and are attended with gesticulations 
of the body, arms, and hands ; the tongue is usually coated 
in the early stages of the disease, and the skin is dry, unless 
in exceptional cases in which there may exist a most dis- 
agreeable odor. 

In connection with these physical changes, there is another 



MANIA. 171 

which is one of the most prominent in cases of acute mania, 
viz., an increase in muscular movements. This is espe- 
cially observable in that portion of the muscular system 
which is under the control of the will ; the patient rarely 
remains quiet, or in one position longer than a few minutes 
at a time ; he is on the move, and all movements appear to 
be executed with the greatest ease and freedom, and with- 
out apparent fatigue. The amount of this activity, which 
delicate females and aged persons are able to make while 
under the influence of maniacal excitement, is almost in- 
credible ; persons who have, for years, been accustomed to 
a sedentary life, and who are ordinarily, when in health, 
fatigued by walking a short distance, when under the 
stimulus of this excitement will pass days and nights dur- 
ing weeks with almost no rest for the muscular system or 
sleep for the brain. The demand of the system for rapid 
and energetic activity appears to be most imperative ; this 
is merely the outward expression of the storm which is 
raging within. In some cases it expends itself in a harm- 
less manner, as in dancing, running, singing, and shouting, 
while in others the movements, as in a paroxysm, become 
suddenly violent in the extreme, and expend themselves 
upon whatever first comes within reach, without reference 
to consequences to either persons or things. The patient 
neither rests himself, nor suffers those about him to rest. 

This continued and excessive expenditure of physical 
energy, sometimes continuing for weeks, and even months, 
has been thought to indicate an increase of strength, as 
compared with that pertaining to a condition of health, but 
in reality there is no such actual increase ; the explanation 
lies in the fact that the person has become partially anaes- 
thetic, and, consequently, insensible to pain and fatigue ; he 
can be controlled easily by an attendant who is of much 



172 LECTURES ON MENTAL DISEASES. 

inferior strength when both are in a state of health ; and 
though able to make exertion continuously for a longtime, 
is totally unable to exhibit any unusual amount of strength 
at any one time. 

In the primary stage of a majority of cases there exists 
an increased supply of blood in the brain. This is indi- 
cated by the distended condition of the capillaries of the face, 
the congested state of the conjunctivae, and the feeling of 
fullness and heat in the head, which may amount to actual 
pain. The temporal arteries pulsate with more than usual 
distinctness, but the action of the heart itself is not much 
above the normal as to frequency of pulsation, unless in 
exceptional cases and during short periods. It has not 
occurred to me to find the pulse slower than usual in cases 
of acute mania, and it is not strong, after the first stage has 
passed, but may be fuller than normal. In the majority of 
cases the frequency of respiration is normal, and the tem- 
perature rather lower than in health. According to Grie- 
singer, the only exception to this is in the case of maniacal 
excitement which sometimes attends general paralysis, when 
the temperature of the body may become increased. 

In nearly all cases there exists an abnormal condition of 
the appetite. This may be either diminished or increased 
or perverted. More often it becomes greatly increased, and 
large quantities of food are taken, though without much 
apparent appreciation as to the usual satisfaction arising 
from using it. It is the quantity rather than the quality 
that is desired, and, indeed, made necessary by the expendi- 
ture of physical force. The taste may become so perverted 
as to lead to eating the excrements, and a special satisfac- 
tion seems to arise from besmearing the face and person, or 
the walls of the room with them, in much the same manner 
as certain animals eat, or rub their bodies in, the excre- 



MANIA. 173 

ments of other animals. Such conditions may be present 
during days or weeks, and yet the patient pass into a con- 
valescent state within a short time. 

In a considerable number of cases there exists a morbid 
excitement of the sexual centres of the brain, which 
causes patients, and especially women, who have, when in 
health, always exhibited the greatest delicacy of speech 
and modesty of bearing, to become vulgar and indecent in 
speech and lascivious in manner. 

It leads, not infrequently, to the practice of masturbation 
in both sexes, and in males in the most open and shameless 
manner. The mistake is sometimes made of supposing 
that the disease is a consequence of various vicious prac- 
tices, whereas, in reality, it is the cause of them. 

In the majority of cases the catamenia ceases after the 
first month of excitement, and does not again make its 
appearance until recovery has become established. After 
the disappearance of the catamenia the morbid sexual 
manifestations are less common. Its disappearance, how- 
ever, has no apparent effect upon the mental excitement, 
and is significant only as indicating how profoundly the 
brain centres are demanding the nourishment of a large 
amount of blood, while its reappearance indicates that there 
is a return to normal equalization of the blood supply of 
the system. In those rare cases in which the suppression 
of menses precedes the manifestations of mental symptoms, 
it cannot be regarded as the cause of the disease, but 
simply as a physical symptom occurring earlier than usual. 
Cases in which there is a sudden suppression of the menses 
from the effects of cold, wet feet, or sudden fright during 
the discharge, and there appears a delirious condition of 
mind, are to be regarded as of quite another character of 
disorder. 



174 LECTURES ON MENTAL DISEASES. 

Cases of acute mania in which the sleep is not greatly 
disturbed are the exception. In fact, insomnia is one of 
the most constant and troublesome of conditions which 
present themselves for management during the continuance 
of the disease, and it is an interesting physiological ques- 
tion why greater injury does not result to the delicate 
tissues of the brain when it passes such long periods of 
great mental activity with so little rest. Such experiences 
in the brain when in its ordinary state of health would 
certainly produce most serious results to the whole system, 
and would prostrate the most vigorous person. The ex- 
planation, without doubt, is contained in the changed blood 
supply of the brain. 

Allusion has already been made to the indications of 
this great change, and it appears to be sufficient to repair 
the large exhaustion which must be constantly going on in 
the sensitive tissues and nerve-cells of the brain, from both 
the physical and psychical activities occurring. It is, how- 
ever, of the first importance that the patient should not 
pass even one whole day without some sleep, and half an 
hour, or even ten minutes, are of great value as a remedial 
agent. A return to or an approach toward normal periods 
of sleep is one of the surest indications of returning mental 
health. As a rule, it requires a long time for the brain to 
resume its normal habit in this respect, even after all the 
mental excitement and delusions have passed away. Wake- 
fulness is generally one of the earlier indications of ap- 
proaching disease, and one of the first about which the 
patient will consult his physician. It may then present an 
opportunity for timely advice in avoiding the threatening 
disorder. 

Variations in general sensations may manifest them- 
selves in^hyperaesthesia, but much more frequently in 









MANIA. 175 

partial local anaesthesia. There may be headache, pain 
in the limbs, sensations of heat in various parts of the body, 
but afterthe condition of mania has become fully pronounced, 
complaints in relation to such experiences are rarely made, 
and patients are quite insensible to exposures to degrees 
of heat and cold, as well as to physical exertions, which 
would be exceedingly objectionable and painful when in 
health. 

Hallucinations of the special organs of sense, particu- 
larly of hearing and smell, are present in from one-third to 
one-half of the cases of acute mania. This would be antici- 
pated from the increased susceptibility of those organs. 
All irritations received upon them become exaggerated, and 
are transmitted to the sensorial centres with abnormal 
rapidity, so that a mistaken interpretation of their signifi- 
cance would be expected. 

For a similar cause, illusions of sight are especially 
frequent. Persons are continually mistaking those whom 
they meet for those whom they have known in the past ; 
they assign forms and dimensions to objects and animals 
strangely at variance with the reality, and are constantly 
misinterpreting the surrounding phenomena. These de- 
rangements of the sensorial centres have been observed to 
be more frequent and more exaggerated in the initial stage 
of maniacal excitement. They frequently reappear after 
having ceased with a return of mental excitement. 

In acute mania, and while the appetite is so keen that 
large quantities of food are daily used, patients may pass 
several weeks without much emaciation. When patients 
refuse to take food, and are not made to do so, indica- 
tions of a loss of flesh and exhaustion soon become appa- 
rent. They also appear when an abundance of food has 
been used, after a long continuance of the active symp- 



I76 LECTURES ON MENTAL DISEASES. 

toms, and especially in cases when the system, at the 
inception of the disease, was in an anaemic condition, or one 
of debility from the experience of other diseases, or from 
protracted application to labor, shocks to the nervous sys- 
tem, sorrow, etc. Whether the disease will prove to be of 
a sthenic or asthenic type will depend largely upon the 
antecedent experiences of disease. 

The more prominent physical' conditions which present 
themselves in acute mania have now been indicated. The 
relative importance which any of them may assume will 
vary very considerably in different cases, but they will 
certainly require the most careful observation and study of 
the physician from day to day. 

Psychical Symptoms. — It has already been remarked 
that patients do not often become excited and maniacal 
without other previous indications of mental ill health. 
These are generally similar to such as exist in the early 
stages of melancholia. Indeed, it is extremely difficult, if 
not impossible, to determine in the outset whether a given 
case may eventuate in one of melancholia or mania, and 
several weeks, or months even, may be necessary to deter- 
mine its future character. In cases of mania, however, it 
is generally true that within a short time a considerable 
measure of restlessness and increase of motor activity 
present themselves, while still the mental depression may 
continue. While the melancholiac is inclined to remain 
quiet, and will not be induced to make much physical 
exertion, the maniac, without suggestion, is disposed to 
wander about, leave his home, visit his neighbors, and 
even strangers, without any definite aim or purpose ; he 
becomes more loquacious than before and speaks in a 
clearer and more elevated tone of voice, complaining of 
such discomforts as he may have experienced from the 



MANIA. 177 

imagined neglect of friends. As the sensations of discom- 
fort disappear, a feeling of satisfaction and good will toward 
every one becomes manifest. The person who 4s naturally 
cautious and timid becomes frank and fearless in bearing. 
The penurious become more generous and even lavish 
in expenditures and benefactions. New enterprises and 
schemes of business become the themes of thought and 
conversation, while the patient rejoices that all his discom- 
forts have disappeared, and that he was never better in his 
life. 

The progressive transformation from a semi-depressed, 
emotional condition to one of exaltation and excitement 
may occur either slowly or quite rapidly. In either case 
the emotional sensibility is the first to become seriously 
affected, and indicates the change from a state of mental 
health to one of disease. The mind begins to act with an 
unwonted freedom and ease ; occurrences and names which, 
perhaps, have not been thought of for months or years 
come back without conscious effort, and with all the dis- 
tinctness and perfectness of their first experience. Pieces 
of poetry and history and snatches of song which have 
not been recalled for years come welling up into conscious- 
ness and demand utterance. They may be recited even 
with a much greater accuracy and readiness than when in 
health. Ideas flow through the brain channels with the 
largest freedom, and form themselves into words without 
effort or will. In fact, during the initial stage, and after 
all feelings of depression have passed away, the action of 
the mind becomes largely automatic, all the faculties tend 
to become highly excited and quickened in activity; the 
memory of former events becomes more distinct, the im- 
agination more excited, and the mind becomes filled with 
16 



178 LECTURES ON MENTAL DISEASES. 

a torrent of images and memories, or false perceptions of 
the special senses. 

As the disease progresses the excitement may increase, 
and anything like clearness of thought and an accurate 
estimate of what may be said and done disappears. All 
thoughts pass so rapidly through the brain as to leave 
very little impress behind, so that the patient appears 
to be only semi-conscious of the character of his expe- 
riences, and not infrequently greatly exaggerates and 
misrepresents them. Certainly, whatever impression he 
may have of them becomes obscure and tends to rapidly 
disappear, while he gives the freest play in recounting such 
imaginary or real past experiences as pass into the field of 
mental vision, and in forming and expressing approval or 
disapproval of persons and events. 

At first these concepts may appear with considerable 
order and distinctness, and be announced with some appre- 
ciation of their relation to the subject-matter occupying 
attention ; but as the disease extends into new areas of the 
cortex, and as the excitement becomes greater, they rapidly 
change from one subject to another, and have very little 
true volitional relation. Indeed, they are often projected 
without any conscious will, and even against it. Still, it 
will be found upon careful observation that the flow of 
mental concepts frequently has some relation to the ex- 
periences of the individual in the past; it may be the 
.occupation in which he has been engaged or some subject 
which has exercised a profound influence upon the mind, 
such as religion or politics or an object of past affection. 
Arising as they do without the conscious action of the will, 
and from the instinctive or acquired character of the brain, 
we should expect them to relate to such subjects to a 



MANIA. 179 

greater or less extent. While there may be, during great 
excitement, confusion of thought, which arises from the 
rapid flow of it, yet, on the whole, there is not an absolute 
loss of coherence of ideas except in cases of delirious 
mania. 

Both Jacobi and Griesinger have called attention to the 
fact that the general conduct of the maniac is wholly 
impulsive or of an instinctive nature, and that it is with- 
out any properly conceived plan or purpose on the part 
of the subject. This results logically from the condition 
of excitement which covers the field of mental activity. 
That element in the formation of mental concepts which 
results from the automatic activity of the brain during 
consciousness, and which, united to the conscious ego in 
health, combines to form a definite act of judgment and 
purpose, is freed largely from the latter element of char- 
acter, and the thought-process moves on without restraint, 
eventuating in words and acts of trie true character of 
which the subject has very little conception. Purpose and 
will require deliberation on the part of the conscious ego 
which is altogether incompatible with the increased activity, 
rush, and whirl of the multitude of concepts which occupy 
the field of mental action. These concepts, therefore, pass 
on in the psychical circle, and combine in such words and 
acts as instinctively arise from the conditions of the brain 
for the time being. It is as if a veil were thrown over the 
mental vision which obscures or blinds the subject as to 
the moral element of conduct. Such sentiments as have 
never been allowed to find expression, nor have been long 
even tolerated in the field of consciousness, not infrequently 
take full possession, and the modest woman or girl, who 
has never in her life spoken an obscene word or harbored 
a lascivious thought, becomes vulgar and lascivious in Ian- 



l80 LECTURES ON MENTAL DISEASES. 

guage and conduct, throws off her clothing, and exposes 
her person without a moment's hesitation. The person 
who has always, when in health, been quiet, undemonstra- 
tive, and inoffensive, suddenly becomes quite the opposite, 
and is ready to match his strength with any attendant or 
physician he may chance to meet. 

In other cases of no less pronounced character, the de- 
gree of excitement may be much less, but at the same time 
the conduct is without any moral basis. Indeed, the 
moral blindness is still greater. The person understands 
quite well, for the time being, what he is about; that he is 
not telling the truth, but, on the contrary, lying ; that he 
is doing what he should not do ; that he is dirty, boisterous, 
destructive, abusive in language, and that he is doing it to 
provoke and annoy those who have the care of him. He 
endeavors to invent all sorts of methods to provoke every- 
body with whom he is associated ; he throws off all restraint 
and urinates and defecates on the floor; smashes his furni- 
ture into pieces, not in any blind excitement or fury, but 
from impulse ; he shouts and declaims on purpose to make 
those about him miserable. When the physician or a 
stranger may come into the presence of such patients, they 
not infrequently exercise, for the time being, enough self- 
control to enable them to reply to all questions intelligently, 
and are always ready with some plausible reason or excuse 
for whatever they may have done amiss ; they are unable 
to perceive any wrong in tearing up or removing their 
clothing, and throwing it from the window or soiling it in 
the water-closet ; at all events, they could not help doing 
what they have done, but will do so no more. Yet, when 
left alone, or out of the sight of the attendant, they imme- 
diately resume their former course of conduct. In the 
majority of such cases, the impressions resulting from what 



MANIA. l8l 

has been said and done by others, or by themselves, appear 
to be exceedingly transient, or so evanescent as to leave no 
lasting effect, and, consequently, are not afterward recalled. 

There are other cases still which exhibit a somewhat 
less marked change in the moral element of conduct and a 
less degree of excitement — cases in which persons can 
appear so sane, and are able to conduct the ordinary affairs 
of life with so large a measure of method and seeming 
reason, that their friends never for a moment suspect their 
sanity. 

They, however, exhibit a change of character, and 
adopt such courses of conduct as are quite at variance with 
their antecedents. Persons who have been all their lives 
frugal, industrious, honest, regular in their habits, loving 
and affectionate toward wife and children, and devoted to 
the highest interests of society, give indications of quite 
opposite qualities of character. They become careless in 
relation to business, lavish in expenditures, ready to un- 
dertake new projects, fond of questionable society, and 
careless of reputation. When expostulated with, they 
become irritable, and not unfrequently abusive. They 
abandon the society of wife and children for that of com- 
parative strangers, enter upon the most risky financial 
transactions, seek the society of lewd women, yet all is 
attributed by friends and neighbors to a spirit of " cussed- 
ness " and innate love of evil courses of conduct. All their 
past life of rectitude and probity goes for naught, and they 
are quoted as affording additional illustrations of total 
depravity. Yet many of them are cases of a mild form of 
mania, in which there has come a film of darkness, cover- 
ing the moral vision, and throwing the judgment off balance, 
by reason of the changed circulation of the brain and con- 
sequent supersensitive condition of certain brain centres. 



1 82 LECTURES ON MENTAL DISEASES. 

If the whole history of such cases could be unraveled, it 
would be found that there had been going on for months 
derangements of the physical organs, as well as of the 
mental functions. They, however, rarely come under the 
observation of the physician, and rarely have the slightest 
suspicion themselves that they require his advice for any 
purpose. 

It should be remarked that as patients approach the 
period of convalescence, impressions of all kinds are 
stronger, more lasting, and leave an effect which can be 
readily recalled to remembrance ; they may also be re- 
counted afterward with more or less accuracy in words. 
Such patients can be influenced by associations with others, 
by changes in rooms and halls, by promises and incite- 
ments in the way of rewards, to exercise a larger degree 
of self-control, and not unfrequently, by such means, rapidly 
pass into a condition of convalescence. 



LKCTURK IX. 



MANIA (Concluded). 

Review of Symptoms — Excitement — Artificial Excitement Produced by 
Various Means — The Thought Process Modified by Changes in Blood Sup- 
ply and by Morbid Processes Affecting the Inhibitory Centres — Failure in 
Power of Attention — The Result of Imperfect Functionating of the 
Thought Process — Fixed Delusions are Rarely Present in Acute Mania — 
Transient Delusions May be Present — Course and Progress of Acute 
Mania — Exacerbations — May Assume a Remittent Type — The Symptoms 
of Other Forms of Disease May Become Modified During an Attack of 
Mania — Counter-Irritation — Terminations — First in Recovery — Danger of 
Relapses — May Pass into a Chronic State — Symptoms of Such a Condi- 
tion — Dementia — Excitement — Delusions — Table of Cases of Acute and 
Chronic Mania — Prognosis — Treatment — Importance of Sleep and Con- 
servation of Physical Strength — Importance of Asylum Treatment — 
Hydrobromate of Hyoscine — Bromide of Ammonium — Chloral — Paralde- 
hyde — Hot Baths — The Wet Pack — Out-of-door Exercise— Cannabis 
Indica — Quiet — Nourishment — Importance of Early Feeding. 

In analyzing the symptoms which we have passed in 
review, we observe that the first and most conspicuous is 
that of excitement. This, in some degree, is an invariable 
attendant during the earlier stages of fully developed and 
pronounced cases. What is the physiological or patho- 
logical condition upon which it depends ? 

In answering this question, it may aid us to refer to some 
causes of excitement acting upon other organs of the body 
than the brain. For example, we may produce an increase 
of heart action by the introduction of certain substances into 

■33 



184 LECTURES ON MENTAL DISEASES. 

the blood, such as alcohol. The contact of this article, 
while in the blood, with the nerve filaments of the vaso- 
motor system, which in health regulate the action of the 
heart, causes a partial paralysis, and this, indirectly, induces 
increased pulsation. A similar effect, though in a less 
degree, may result from other causes, such as an intense 
and continuous attention directed toward the action of 
the heart. In the former case there is produced a partial 
paralysis of the vaso-motor nerves, resulting indirectly in 
an increase of pulsation, and in the latter an increase of 
nerve-energy appears to pass directly into the motor sys- 
tem. In both cases a similar effect follows. This increase 
of function may continue within certain limits as to time 
and degree of intensity, without any consequent disease ; 
but, beyond these limits, which vary in different cases, the 
action becomes excessive or irregular, and disease appears. 
The lesion consists in a disturbance of the normal balance 
existing between the two systems of nerves. 

Now, excitement in that portion of the brain which is 
concerned in the evolution of thought may be produced in 
a like manner by the introduction of, for example, tea, coffee, 
or alcohol to the circulation. The presence of the ultimate 
particles of these substances in the blood, and acting upon 
the nerves of the blood-vessels, causes them to dilate, 
which results in an increased flow of blood to the brain- 
cells. The presence of a sufficient quantity of properly 
aerated blood in the grey substance of the brain is essen- 
tial at all times for the discharge of the thought function. 
A less amount than the normal supply slows the thought- 
process and modifies its character, as shown in melancholia. 
The reverse is equally true ; an increased amount of healthy 
blood in the brain (unless it becomes too great) causes 
an increase in the product of thought. In a like manner, 



MANIA. 185 

the continuous concentration of the attention on any special 
subject of thought, a profound grief or disappointment, a 
moral shock, all affect the thought-process by causing a 
more or less serious lesion of the inhibitory centres. The 
thought-process in health is largely automatic ; thought of 
some quality comes whether we will or not ; but while the 
two systems of nerves are properly counterbalanced as in 
health, the will may change the current of the thought, and 
modify its character to a greater or less extent. Now, in 
mania, the free exercise of the will power is invariably more 
or less impaired, and there can be no doubt that this is the 
result of a lesion of the inhibitory centres. Mental con- 
cepts form and pass through the psychical circle of the 
brain with an abnormal rapidity and persistence for the 
time being. Within certain limits as to time and degree, no 
special harm may result; the action may be modified and 
controlled by the will, but when these limits are passed, 
the thought-process becomes persistent, morbidly exces- 
sive, irregular, and disordered, and we have the excitement 
of acute mania. 

Another very common symptom present in conditions of 
acute mania is a failure in the power of attention. The 
extent of this lesion varies largely in different cases, as 
does the degree of increased excitement, but difficulty in 
fixing the attention, except for a very limited time, is a 
noticeable feature in most cases. If, for the time being, it 
has been secured, it may speedily become diverted by the 
most trivial incidents, such as the passing of a person, a 
distant sound, as of the human voice, or the song of a 
bird — in short, any occurrence or sound which may reach 
the ear. Continued and fixed attention to courses of 
thought which may be passing through the brain, and, no 
less to external occurrences, is a prime requisite to insure 



1 86 LECTURES ON MENTAL DISEASES. 

an ability to recall them afterward. This is true in the 
ease of the healthy brain. Very little of what may have 
passed before the eyes during a ride through the crowded 
streets of a strange city, or during the excitement of a pro- 
longed battle, can be recalled with any degree of accuracy 
by even a strong mind, unless the attention has been fixed 
upon definite objects and occurrences at the time when 
observed. In either case a vastly greater number of per- 
sons and events pass before the eye than can ever again 
be recalled. 

How much more true must it be as to what passes sub- 
jectively or objectively during the storm-period of an attack 
of maniacal excitement. Hence, nearly the whole period 
ever afterward seems a blank to those who have recovered 
from an attack of acute mania in which the excitement was 
very great. 

Lesion of attention doubtless results largely from the 
rapidity and imperfect functionating of the thought-process, 
and the consequent evanescent character of impressions 
made upon the brain. The thought-images appear and 
vanish on the confused mental vision in such rapid succes- 
sion and with such changing hues and colors as to 
preclude much effort to attend to them. The condition, 
therefore, is the legitimate outcome of the character of the 
brain action, and has been thought to depend upon the 
lack of balance, or of co-ordinating power in the different 
sections of the brain. If this means a derangement of the 
normal balance of nerve energy as between the two great 
systems of nerves, it is doubtless true. It has been sug- 
gested that the symptom of excitement itself may arise 
from this cause, and the lesion of attention may also do so 
in no less degree. 

The two symptoms, excitement and lesion of attention, 



MANIA. 187 

are quite sufficient to explain, not only the impairment of 
memory, as already indicated, but also that of self-control 
and judgment, both of which are generally present in 
mania. 

Clearly defined and fixed delusions are rarely present 
in acute maniacal excitement. Indeed, they would be quite 
inconsistent with this character of mental activity. The 
vitiated quality of thought consists rather in the ideas 
which do not remain in the field of consciousness long 
enough to become beliefs of any kind, and generally not 
long enough to become correct ideas. In the condition of 
the nerve centres incident to this state, as above explained, 
the irritations which impinge upon the organs of sense, or 
the nerves of sensation, flash through the nerve-channels, 
leaving only the faintest impressions, and, consequently, 
give rise only to simple fragments of ideas, which are 
equally transitory. A belief, therefore, whether true or 
false, can hardly be supposed to be developed anew, and 
only such ones present themselves temporarily in conscious- 
ness as may have been formed in it while in a previous 
condition of health, and the memory of which may come 
into consciousness for the time being. 

The supersensitive condition of the brain centres 
and the increased amount of blood present in the vessels of 
the brain give rise to wrong impressions, which, in their 
turn, generally give rise to equally false views concerning 
persons and things ; a movement on the part of an attend- 
ant, a word, an inflection or tone of the voice in speaking, 
is misinterpreted simply because of the rapid flow of other 
half-formed concepts. And each new excitation causes a 
new crowd of images and delirious concepts to arise, which 
do not remain long enough to become crystallized into any 
quality of belief. This, however, is not true in cases in which 



1 88 LECTURES ON MENTAL DISEASES. 

the degree of excitement does not become so pronounced, 
and in which there appears a degree of method in conduct 
and coherence in ideas. 

Delusions of a transitory character are not uncommon 
in such cases, — the patient feeling that he is a person of the 
largest importance, that he has filled positions of authority 
and influence in the past, and is now incarcerated simply to 
deprive him of his rights. A young man came under my 
care formerly, who had been engaged as a book-agent, and 
had been fairly successful. While attending some religious 
meeting, he became impressed with the belief that he ought 
to become a preacher, and, soon after that, he actually had 
become one. He prepared and delivered several sermons 
in a school-house, to willing hearers, but soon after became 
so much excited that he was brought to the Retreat. This 
movement on the part of his friends he resented very 
stoutly, declaring that he had letters of the highest com- 
mendation in his pockets in relation to his ministerial 
abilities, and that to take him away, just as he was thus 
engaged in preaching one of the greatest sermons ever 
preached in the State, was an outrage which should be 
punished in the severest manner. This delusion, however, 
remained but a short time, and gave way to others equally 
transient in character, and he soon passed over into the 
condition of excitement in which nearly all sequence of 
ideas was lost, while his mind went stumbling on from one 
to another with the greatest irregularity. 

In chronic and special forms of mania, the false concep- 
tions and dominant ideas generally pass over into defined 
delusions with greater or less intensity and duration. 

The course and progress of acute mania vary very 
largely in different cases, even when there may exist no 
apparent assignable cause for such variation. The maniacal 



MANIA. 189 

condition may continue for a few weeks only, or it may 
extend over a period of months. A stage of continuous 
mental excitement with restlessness and large increase of 
motor activity may be continuous, or the excitement may 
subside for short periods to be again renewed. In such 
cases there is no real remission, but simply a diminution, 
for the time being, of the intensity of the mental and physi- 
cal activities. The length of time, however, during which 
such remissions may continue, and also the degree of 
remission, will greatly vary in different cases, and, in some, 
may continue for several months. A female patient for- 
merly in the Retreat experienced as many as thirty of these 
remissions within a few years, during which she could 
reside with her family. In such cases a true neurosis 
becomes established. 

These exacerbations may assume a true remittent type, 
the patient being excited on alternate days or on every 
third day. It has occurred to me to observe only three 
such cases, two of them being under my own care. The 
cause of these regular remissions was not apparent ; it 
certainly did not appear to be of malarial origin, so far as 
ascertained. Quinine was used freely, but produced no 
effect in checking their appearance, though they ceased 
after the long-continued use of arsenic. Whether this was 
due to the effect of the drug, or to the fact that the course 
of the disease naturally terminated, is not clear. 

It is commonly observed that when the menstrual flow 
continues monthly during an attack of mania, its presence is 
attended with an increase of mental and motor excitement. 

It has often been observed that the symptoms of other 
forms of disease which may have existed during months 
or years may largely or entirely subside during an 
attack of mania. 



190 LECTURES ON MENTAL DISEASES. 

This is especially noticeable in cases of phthisis. A 
young lady was recently in the Retreat during an attack of 
acute mania, from which she made a most happy recovery, 
who, when admitted, was suffering from a severe cough, 
and had experienced several hemorrhages from the lungs. 
In her case the degree of excitement was less intense than 
is sometimes observed, but still was very considerable, and 
extended over a period of several months. After the first 
six weeks the appetite became very keen, and she took 
large quantities of food ; the cough entirely disappeared, 
and she gained, during the progress of the disorder, more 
than fifteen pounds in weight. It is not to be inferred, 
however, that there was a return of healthy tissue in the 
lungs to any considerable degree, but only that the objec- 
tive indications and former progressive development had 
been checked by means of changes in the circulation and 
in the quantity of nerve energy present. Such modifica- 
tions of symptoms sometimes occur, for short periods only, 
in typical cases of phthisical insanity. 

Again, the progress of the disorder may sometimes be 
arrested and cut short by the appearance of some other 
form of disease, such as a carbuncle, or several boils, or 
an attack of intermittent fever, or again, by profound impres- 
sions made upon the nervous system through the occur- 
rence of accidental injuries. Such effects would appear to 
be allied to those sought to be produced a century or less 
ago by plunging patients into baths unexpectedly, or by 
submerging them under water until partially suffocated. 

An ingenious arrangement for this purpose existed in 
one of the oldest institutions for the insane in America, by 
means of which the patient, securely fastened into a chair, 
was lifted and rotated about by machinery until over a 
large tank of water, and was then suddenly let down into 



MANIA. I9I 

it, where he remained during the pleasure of the operator. 
The operation could be repeated as many times on any 
occasion and as frequently as prescribed by the physician, 
and to the heart's content of the attendant in case the 
physician did not choose to superintend the administration 
of his own prescription. 

Some cases of violent mania may be arrested by the 
effects of a counter-irritation applied to the head, or nape 
of the neck, or to both, in the form of a blister, which should 
be large enough to create a condition attended with inflam- 
matory fever. Also occasionally by the prolonged use of 
hot baths, during the administration of which cold applica- 
tions are made to the head. It should, however, be remem- 
bered that such remedial measures are successful in a very 
few cases only, so few, indeed, as to be regarded as excep- 
tional ones. 

Termination. — Acute mania may terminate in any one 
of several ways. First, in recovery. When this is the 
case, the excitement generally becomes less ; the attention 
can be more easily secured, and for longer periods; the 
patient responds more readily and intelligently to inquiries 
addressed to him. He begins to pass longer periods in a 
sitting posture and sleeps more hours, and with less of 
medicine to induce sleep. As he begins to come to him- 
self and realize that he has been ill, and is now in unusual 
conditions, he becomes less inclined to talk, and avoids 
alluding to his past condition, and may, when alone, seem 
to be slightly depressed. When the excitement has been 
intense, he has no idea as to the period of time passed since 
he was brought to the asylum, and may have no recollec- 
tion of coming. The transition to a state of health may 
occur within a short time, or it may be very gradual, and 
extend over several weeks, and even months, before the mind 



192 LECTURES ON MENTAL DISEASES. 

resumes its former activity. When the patient begins, to 
talk of home and friends, and his interest in them returns, 
and also his interest in his former pursuits, it is a very- 
favorable indication, though much care should be used to 
prevent a too speedy return to the cares and responsibilities 
of business. 

When patients are overjoyed at the prospect of a speedy 
return to their families, and very confident that they are 
fully able to resume the routine of home life, the perfect- 
ness of recovery may be regarded with doubt. There exists 
in such cases a special danger of a return of the excite- 
ment. Self-control, with a tendency to distrust one's 
ability to resume life outside an asylum, is a far better 
indication. 

It should be remembered that a brain which has passed 
through the excitement and strain incident to an attack of 
acute mania is, perhaps, ever afterward more liable to 
another. A special character of brain action has been 
experienced, and a tendency toward a recurrence of it will 
exist during a longer or shorter period in all cases. This is 
true after an experience of disease affecting some other organs 
of the body, and is to be anticipated and especially guarded 
against after an attack of mania with greater care than is 
necessary after an experience of melancholia. The length 
of time which may pass before the occurrence of another 
attack of abnormal activity in the brain will depend largely 
upon the inheritance of the individual, the perfectness of 
the recovery before leaving the asylum, his circumstances 
in life, and upon the degree of intelligent care exercised by 
him to avoid it. 

Besides, it should always be borne in mind that there 
exists a physiological tendency in the brain and nervous 
system to periodical changes as to degree and intensity 



MANIA. I93 

of functional activity, and that this latent tendency is liable 
to force itself into an actual one in every brain which has 
passed through the storm of mania. This, therefore, is 
another and most important factor requiring to be con- 
sidered in prognosing the probable termination of an attack. 
Allusion has already been made to a case in which this ten- 
dency became converted into a true neurosis, and in which 
there occurred no less than thirty pronounced attacks of 
maniacal excitement within a few years. Other cases are 
on record in which a larger number are mentioned. If, 
however, the system can be tided over a considerable 
period, say one or more years, this tendency may largely 
and rapidly diminish, and may again manifest itself only at 
the critical periods of life, or after prolonged exposures and 
severe brain experiences. 

Again, acute mania may pass into a chronic condition. 
The period beyond which cases are reckoned as chronic is a 
purely arbitrary one ; but there appears to be a consensus 
of agreement that when a case has passed the twelfth month 
it is to be regarded as chronic. This period of time may 
be used to indicate chronicity in cases of mania much more 
appropriately than in melancholia, inasmuch as recoveries 
from mania are much less frequent after twelve months 
than in melancholia. The mental and physical symptoms 
in chronic mania are usually less intense than in acute ; the 
degree of excitement is less, and the power of inhibition 
greater. The hallucinations and delusions are of a more 
pronounced and definite character, and remain longer in 
the field of mental vision. There is rarely observed derange- 
ment of the bodily secretions, the motor excitement is 
moderate, the appetite and digestion good, menstruation 
reappears in females, and bodily health may remain good 
for years. The condition of the memory varies much in 
17 



194 LECTURES ON MENTAL DISEASES. 

different cases ; while in some it may be perfect as in 
health, in others it is efficient only for short periods. 
Whatever of dementia is present is perhaps manifested as 
much in impairment of memory as in any other way. The 
moral sentiments are blunted, and are little affected by such 
stimuli as usually arouse them when in a state of health. 
The expressions of joy or sorrow, happiness and misery, 
are rarely alluded to, while a revival of interest in former 
occupations, interests, and modes of life very rarely appear. 
The degree of mental improvement will also depend upon 
the tenacity and definiteness of such delusions as may be 
present. 

In a small proportion of chronic maniacs there occur 
short periods of great excitement during which patients 
manifest the most aggravated symptoms of the acute con- 
dition, becoming violent in the extreme, tearing clothes and 
bedding into shreds, breaking furniture, and every destructi- 
ble thing upon which they can lay hands. Such periods of 
excitement, however, are not generally prolonged, and the 
physical health may remain unimpaired. 

The delusions of chronic mania are rarely of the depres- 
sive type, but, on the contrary, are generally those of self- 
importance. The patient imagines that he possesses greater 
power and influence than ever before, and the delusion may 
extend to supposed change in his personal identity. Indeed, 
this not unfrequently is the case, and he becomes an em- 
peror, or an ambassador, or some special messenger of the 
Divine Being. 

Persons affected with chronic mania may, and generally 
do, live many years, unless there should arise some form 
of physical disease which ends the life. This is especially 
the case when a patient passes his time in an asylum, where 
he is little exposed to the frictions and excitements, irrita- 



MANIA. 



195 



tions, and such unfavorable conditions as would be sure to 
affect his health if he were living under only the ordinary 
restrictions of home life. Regularity as to the hours of 
meals, and the time of retiring and arising, bathing and 
exercising, are of importance in the degenerate and irrita- 
ble state pertaining to chronic mania. 

Finally, acute mania may terminate in dementia, in 
which there exists an enfeeblement of all moral and intel- 
lectual faculties of the mind. Such an issue without doubt 
arises from the extent to which the physical disorder had 
affected the tissues of the brain and its membranes. When 
these have become changed through the deposits of adventi- 
tious or inflammatory products, and thickened by organic 
lesions, the mind is very likely to pass into a condition of 
dementia. 

The following table indicates the total number of cases 
of both acute and chronic mania which have been received 
at the Retreat during twenty years, and the terminations as 
far as known from the records. By this it appears that 



Acute mania, 

Recoveries, 

Deaths, 

Otherwise, 

Improved, 

Stationary, 

Chronic mania, . . . . 

Deaths, 

Stationary, 

Improved or recovered 



c 

•0 

CO 
CO 

25 

II 

I 

21 
2 


i 

co 

- 

54 
27 

9 
1 

13 
4 


•s 

41 

18 

9 
° 

• 


m 

c-^ 

<N* 
00 

43 

1 


10 
4 


"s 

CO 

34 
14 
4 

14 
2 


In 

00 

34 
20 

3 



7 
4 


mo 

c^ 

i* 

CO 

42 
23 

3 


6 
10 


'•C 
r^ 

23 
13 
2 

I 

4 
3 


CO 

H 

: 

14 


1 
5 


co" 

19 

9 
3 

4 
3 


6 

CN 
t> 

CO 

31 
*9 

I 

6 
5 


d 

\ 



CO 

45 
17 
12 

5 
11 


co 

CO 
CO 

3-3 
17 
I 

3 
9 


00 
\ 

N 
OO 

CO 

33 
18 
2 

5 
8 


CO 

00 

T 9 
9 

2 

3 
5 


in 

CO 

CO 
00 

27 
17 


5 
4 


s° 

co' 

38 

21 

5 

3 
9 


•0" 

15 

2 
O 

4 

5 

4 


??' 

13 
11 
1 




6\ 

CO 

co* 

30 
00 

12 

II 
O 
O 
O 

I 



633 

331 
72 

7 
[28 

95 



„, 4 


10 


11 


9 


21 


24 


19 


2321 


17 


,0 


6 


13 


18 


II 


4 


20 


4 6 


1 





1 


b 


5 





4 3 











1 





I 


1 





7 | 8 


8 


6 


4 


9 


12 


13 


14 16 


14 


7 


5 


8 


8 


6 


1 


'4 


90 


1 


5 


4 





7 


6 


5 2 


3 


3 


1 


4 


IC 


4 


2 






6288 



there was a " recovery " record in 52.1 -\- per cent, of acute 
cases, and " an improved" record in 20.2 -f- per cent. Of 



I96 LECTURES ON MENTAL DISEASES. 

those reported as "improved" the larger number were 
prematurely removed from the institution and their his- 
tories remain unknown. 

Of the chronic cases it is found that 27.4 + per cent, 
either improved or recovered. 

Prognosis. — The prognosis will depend largely upon 
the duration and the intensity of the morbid process, the 
complications with other diseased conditions, such as phthi- 
sis, chronic debility of the assimilative system, etc. When 
occurring before sixty years of age, and uncomplicated, 
and when it has not so far affected the brain as to cause 
violent congestions, it may be regarded as favorable. 

Statistics indicate that something more than fifty per cent, 
make recoveries. Of the 633 cases of acute mania ad- 
mitted to the Retreat during the last twenty years, 330 
recovered, 72 died, 128 improved, and 96 passed into 
a state of chronicity. The issues in the remaining number 
do not appear from the records of the institution. 

Treatment.— It may be remarked in relation to the 
treatment of acute mania that when once it has become 
fully developed it is rarely " broken up " or " cut short," 
i. e. } it passes through several degrees of morbid excite- 
ment and continues for a longer or shorter time, which 
period does not apparently depend much upon any system 
of radical treatment. Convalescence then becomes estab- 
lished or the patient passes into some one of the other 
conditions to which allusion has already been made. It 
was formerly the fashion to talk of " breaking up " typhoid 
fever, and some physicians used to claim special skill and 
success in securing such an issue of cases by treatment, 
provided only they could have charge of cases in the early 
stage of the disease. When, however, such a result was 
not secured — why, they were not called to prescribe soon 



MANIA. 197 

enough. Such a belief as to typhoid fever has long since 
passed into the limbo of other exploded notions. In the 
case of mania it might not be safe to conclude as certainly 
that it is never " cut short " by some course of efficient or 
heroic treatment, but the diagnosis would surely in such 
cases be open to question. It is quite certain that such re- 
sults rarely or never follow from any course of treatment 
adopted after patients with acute mania are admitted to 
asylums. On the contrary, the disorder continues in the 
majority of cases for two or more months, in spite of any 
ordinary or extraordinary system of management which 
may be adopted. Indeed, so generally is this the case, that 
we are led to doubt the genuineness of those cases which 
are cured in a few days. 

In the management of acute mania there are three special 
desiderata to be attained, if possible; first, moderation of 
the excitement ; second, several hours of sleep every 
night ; third, conservation of the physical strength. 
To secure the first of these objects, nothing is more efficient 
than a removal from home to a well regulated and fully 
equipped institution, where the patient may be under the 
immediate supervision of strangers who are familiar with 
the management of such patients. The conditions of mania 
are generally so urgent, and it is so extremely difficult to 
care for them in a home, which they are all the while con- 
verting into a pandemonium, that friends are only too glad 
to have patients removed after the first few days of effort to 
care for them. Individual cases are sometimes met with for 
whom it may be important for various reasons to avoid an 
admission to an asylum, or even to a private establishment 
for the care of the insane. When such is the case the 
patient should be removed from his family and placed in a 
house obtained for the purpose, and under the immediate 



I98 LECTURES ON MENTAL DISEASES. 

supervision of trained attendants, and with a resident phy- 
sician, if possible. 

Of medicines to allay the morbid motor activity, when 
ordinary preparations are refused, I have found the hydro- 
bromate of hyoscine one of the best. It may be given 
once or twice in the twenty-four hours, in doses from one 
hundred to one seventy-fifth of a grain, either hypoder- 
mically or in milk and water, or tea. As it is tasteless, the 
patient is unaware of having taken any medicine. Conium 
and bromide of sodium and bromide of ammonium may 
also be used to allay restlessness, and are especially indi- 
cated whenever (as is very often the case) a morbid excite- 
ment of the sexual centres of the brain may be present. 
Chloral and paraldehyde are also among the most efficient 
hypnotics. The use of the prolonged hot bath, with a 
temperature of from 85 to ioo° Fahrenheit, and even higher 
in some cases, is of special value. The patient may be intro- 
duced to the bath at say, 70 degrees, and then the tempera- 
ture gradually increased as he becomes accustomed to it, 
until it is as high as is desired. Patients may be kept in a bath 
from fifteen minutes to one hour, and should always be 
under the observation of the physician, and the pulse care- 
fully observed. French physicians, for many years, have 
been accustomed to use baths of a higher temperature than 
above mentioned. I am, however, unable to recommend 
the practice, though it may be of service in some cases, as 
it is attended with danger. 

Some alienists of Great Britain are in the habit of using 
the wet pack, which may be prepared as follows : — 

A sheet is wrung out of cold water, then placed upon a 
Mackintosh blanket, and both laid upon a mattress. The 
patient, the clothes having been removed, is then placed 
upon the sheet, and it, with the blankets, is folded about 



MANIA. 199 

his person, and he is then covered with woolen blankets. 
He is left in this condition for half an hour, then removed 
and showered with cold water, rubbed, and placed in bed. 
The process may be repeated during the day if thought 
advisable ; cold may be applied to the head while the 
patient remains wrapped in the blanket. 

Some Scotch alienists, especially Drs. Sibbald and 
Clouston, have strongly recommended the practice of exer- 
cising highly excited patients by walking them between 
attendants long distances, or until a considerable degree of 
exhaustion is secured, for the purpose of quieting them. 
There can be no question that this practice for some cases, 
and in certain environments, is highly serviceable. It is, 
however, more practicable in such a climate as that of Scot- 
land than in such a one as pertains to the Northern States 
of this country. In either the heat of summer or the 
cold of winter it would not be available. Besides, many 
maniacal patients are already in a condition bordering 
upon exhaustion from continued excitement, or in an 
anaemic state, when admitted. In suitable cases I have 
used this means for allaying excitement and securing sleep 
with much success. 

In not a few cases the degree of excitement is greater 
than would otherwise exist, in consequence of an anaemic 
state of the system, and also because the patient has not 
taken a sufficient quantity of nourishment. In such cases 
one of the most efficient means of allaying the excitement 
and motor activity is the administration of beef tea, beef 
extract, or eggs and milk, with one-half ounce of whisky 
every few hours. Beer or ale may also be given after food 
with advantage. 

2d. The second indication is to secure sleep. Each 
one of the above measures will greatly conduce toward 



200 LECTURES ON MENTAL DISEASES. 

this, and in some cases will prove to be all that is required. 
In other cases some form of drug will be necessary. 
When the system is well nourished and the pulse strong, 
the bromides in dram doses are indicated and are a most 
valuable remedy. Dr. Clouston strongly recommends their 
use for limited periods combined with the tincture of can- 
nabis indica in one-dram doses. 

I have found the combination of chloral with the bromides 
better than any other remedy. The bromide of camphor 
may be serviceable in some cases in which the excitement 
is not very great. The bromides may be used during the 
day, and thirty grains of chloral at night. In some cases, 
with a condition of anaemia, I have secured good results 
by the use of morphine, but never use it for those patients 
who have a strong pulse or when there are indications of 
a congested state of the vessels of the brain. Under such 
conditions it aggravates rather than relieves. Paraldehyde 
has been recommended as very satisfactory in some cases, 
but I have not obtained any advantage which cannot be 
equally secured with chloral, and I think with better after 
effects. Sulfonal and chloralamid have more recently 
appeared as soporifics and have proved of special service 
as such. In some cases, confining the patient in a dark 
room is an efficient means of securing sleep, and, besides, 
is very grateful. Not infrequently there exists a sensitive 
condition of the retina which will account for this. 

3d. Nourishment. — It may be laid down as a rule to 
which there are very few exceptions that all cases of acute 
mania require a large amount of highly nourishing food 
daily, and if it is refused, or not voluntarily taken, it should 
be introduced to the stomach by means of a tube. It is a 
serious mistake to long delay resorting to forced alimenta- 
tion in such cases. Indeed, it is difficult to conceive of 



MANIA. 201 

physiological conditions of the system which more urgently 
require large supplies of nourishment than those which 
exist during the initiatory period of acute mania. Every 
day passed by the patient in the physical and mental 
excitement which are often present, without food or with 
but little, causes a larger loss of energy than three days 
under other conditions ; and it is to be borne in mind 
that the period to be passed in the progress of the dis- 
ease is not measured by days, but by weeks and months. 
The strain will come, therefore, in its greatest intensity 
later, and if the strength has been well sustained by a 
highly nutritious diet, the system will be all the more 
sure to resume its normal condition. Resort should be 
had, therefore, early to the introduction of beef tea, strong 
soups, milk and whisky, eggs beaten up with milk, and in 
case the stomach is deficient in digestive activity, some one 
of these articles should be given in small quantities every 
few hours. The conditions of the alimentary canal, as 
indicated by the tongue and mucous membrane of the 
mouth, should not cause an hour's hesitation or delay. 
After the initial period has passed, the appetite will return 
and sufficient food will be voluntarily used. 



IvKCTURK X 



PRIMARY DELUSIONAL INSANITY. 

Mode of Development — Contrasted with those of Melancholia and Mania — 
Patients not much Excited or Depressed by the Presence of Delusions — 
Chief Sy/nptoms of the Disorder— Delusions Arise de novo, and are not 
the Result of any Antecedent Mental Disease — ^Etiology — A Neurosis 
Inherited or Developed — Imperfect Development of the Bones of the 
Skull — Meningitis, Injuries, etc. — It more often Appears during the 
Epochs of Life — Symptoms — In the Prodromatous Stage — Tendency to 
Solitude — Distrust — Eccentricities — Irritability and Brooding — Tendency 
to Reverie and Subjectivity — The Primary Stage may Cover Months or 
Years — The Essential Element of fully Developed cases is Delusions 
— Hallucinations of General Sensation — Often Present in the Back, Sides, 
and Genital Organs — The Character of Delusions may Partake of Exal- 
tation or of Pseudo-Depression — Memory — Illustrative Case — Letters of 
the Patient — Personality Overwhelmed by the Strange Concepts and 
Dominant Ideas, etc. 

Mode of Development. — We have now traversed the 
two great fundamental departures from the standard of 
what may be assumed to be healthy mentality. 

The first of these was in a line of diminution of functional 
activity, attended with mental suffering ; the second in the 
opposite line of increased functional activity, and attended 
with exhilaration. Both of these conditions, you will bear 
in mind, have been shown to be accompanied or followed 
by delusions, illusions, or hallucinations, insistent ideas, and, 
in some instances, all of these. Further; in the condition 
of both mania and melancholia, the symptoms which gave 

202 



PRIMARY DELUSIONAL INSANITY. 203 

names to them constituted the underlying and principal 
features of the disorder, while the hallucinations and delu- 
sions assumed a secondary position, apparently growing 
out of, and depending upon the former, and they faded 
away largely in proportion as the conditions from which 
they arose and upon which they depended improved. 
This, however, was not the result in all cases. A very con- 
siderable percentage, after the conditions of mania and 
melancholia had passed away, remained still affected with 
delusions of different kinds, and also with hallucinations. 
These peculiar phantom-like creations which had been 
projected into the conscious sphere of thought, while its 
mechanism was burdened by a supersensitive or neuras- 
thenic condition, made so profound an impression, or 
became so fully imbedded, as to remain long after the con- 
dition itself, which was the indirect cause of them, had 
improved, thus constituting a secondary, sequential, or 
chronic form of abnormal mental activity. 

We now enter upon the consideration of a third line of 
departure from the assumed standard of healthy mind, the 
general trend of which leads away from that of either of 
the above forms, and, indeed, rarely crosses or intersects 
with either of them, except in an incidental way. It is a 
mental state or condition by no means as common as the 
first two, and yet is frequent enough to be found in all large 
asylums, and in some of them in considerable numbers. 

In this form of mental disorder neither of the two prin- 
cipal mental conditions which we term mania and melan- 
cholia is found to exist in any marked degree. While 
some cases are attended by such mental changes as would 
ordinarily indicate a condition of depression, or, at least, 
a physiological basis for it, yet the individual does not 
pass into a state of melancholia. He may be mentally 



204 LECTURES ON MENTAL DISEASES. 

burdened, and be constantly apprehensive of evil about to 
happen to him, but he does not on that account suffer in 
mind as the melancholiac does ; he is never overwhelmed ; 
he never despairs ; he never speaks of not becoming well, 
or of troubles which he anticipates for his friends or family ; 
he seems to be profoundly unconscious that there is any- 
thing the matter with him, and converses about his delu- 
sions of persecutions as a matter of fact, and troublesome, 
but something to be escaped from by using the proper 
means. 

Again, he may be never so sanguine as to his future 
prospects and his present fortune ; he may be confident he 
is an emperor, for a little while debarred from his rightful 
throne ; or Paul the Apostle, or Jesus Christ even ; that he 
is worth untold millions, and has missions of the highest 
importance to fill ; and yet he never becomes excited about 
it; he does not become incoherent or maniacal, or deduce 
illogical conclusions from the assumed premises. The 
failure in his reasoning consists largely in the assumption of 
premises which do not exist. If these were true, the infer- 
ences and conclusions which he reaches in a very straight- 
forward and consistent way would not be so far wrong or 
highly improbable. No very marked degree of mental en- 
feeblement or dementia or of mental inactivity appears for 
several years after the disorder has become fully developed. 

Hallucinations and delusions of different kinds and 
characters appear to constitute the permanent characteristics 
of this form of mental disorder. And it should be noticed 
that these are not the residue of any antecedent attacks of 
systematized insanity, nor due to the after effects of such, 
nor do they constitute the after effects of either excitement 
or depression. Whatever of the latter may have existed in 
the earlier stage, is not more than is compatible with 



PRIMARY DELUSIONAL INSANITY. 205 

mental integrity and ability on the part of the personality 
to distinguish properly and interpret all sensations and 
experiences. 

That peculiar supersensitive condition of certain portions 
of the central ganglia, or certain cortical areas of the brain, 
which constitutes the basis of hallucinations, is not in this 
variety due to an extension of disease which formerly 
existed in other portions of the grey substance, but, on the 
contrary, appears to arise de novo, and to become the 
point d'appia, whence it is radiated to other limited sec- 
tions of the cortex, thus furnishing a basis for delusions of 
a primary character. 

The emotional system, which contributes so important 
an element and the disturbance of which plays so large a 
part in some other forms of mental disorders, remains 
mostly unaffected in this. Whatever of excitement may 
appear seems to depend upon the morbid beliefs of the 
patient, and may become considerable during short periods 
in connection with delusions of persecution. 

Etiology. — A neurosis — either inherited or developed 
from experiences incident to early life, such as infantile con- 
vulsions, delirium, or the disorders of childhood; imperfect 
or arrested development of the bones of the skull ; mening- 
itis occurring in childhood from falls, blows, or other con- 
tusions to the skull; injuries affecting the nervous system 
from frights and over-study at this period ; or, finally, from 
impressions received while still in utero, — usually manifests 
itself at an early period of life, and generally during 
adolescence. 

The proximately exciting causes of the development of 
this form of disease are less pronounced than in many 
others. In those cases which have come under my obser- 
vation it has been connected more often with the advent of 



206 LECTURES ON MENTAL DISEASES. 

puberty, adolescence, and the climacteric ; or, again, with 
masturbation and systemic diseases occurring in the early 
period of life, and profound impressions and injuries. 

The environments have been favorable ; educational ad- 
vantages and positions in society good, and those unfavor- 
able influences which arise from poverty, over-work 
(except in cases of study), anxieties and disappointments, 
have not existed. 

Symptoms. — The disease appears generally to develop 
in connection with the growth of the system, though, as 
already remarked, it may arise at later epochs in life in 
some cases. In the prodromatous stage there may be an 
increased tendency to solitude and a growing distrust 
toward those who have been friends for years, combined 
with an exaggerated degree of self-importance, and still the 
individual appears so natural, and, when once engaged in 
actual intercourse, converses so nearly as he always has done, 
that no suspicions arise as to the oncoming of disease. Its 
primary indications may consist in eccentricities ; singularity 
in general conduct; too little inclination to participate in 
the sports and experiences common to childhood ; peculiar 
fancies, and a tendency to indulge dream-like states and 
reveries, while half unconscious of what may be passing 
about him ; a state of abnormal irritability and supersensi- 
tiveness if disturbed; an inclination to solitude and intro- 
spective periods at that age when normally constituted 
children are expending the surplus of nervous energy in 
outward activities and the motor centres are especially 
sensitive and active. Such conduct is characteristic of and 
normal to the individual, as ordinary conduct is to persons 
in general, thus indicating how profound is the impression 
of the inheritance, or accidental experience, upon the 
organization of the nervous system. It is so potent an 



PRIMARY DELUSIONAL INSANITY. 207 

element that it becomes ingrafted into and develops in 
connection with the growth of the system, thus rendering 
it handicapped from the beginning of life. 

It does not, however, affect the development of the mental 
life in such a manner as to greatly hinder or check its 
activity. The mental life does not become hazy or dull, 
and such progress is often made in school as is common for 
young persons; and when the morbid state has finally 
affected the system so as to produce disorder of the mind, 
while it may, and generally does, tend toward enfeeble- 
ment, it does not produce dementia of a pronounced 
character, but, on the contrary, the mind continues espe- 
cially active in many spheres of thought. 

One of the cases illustrative of this form of mental dis- 
order, and which has been under my observation twelve 
years, while showing indications of lessened mental and 
physical vigor, yet reads Latin, Greek, and German ; is 
interested in, and regularly reads, the London Saturday 
Review, and has done so during many years. 

When, however, the elements of mental activity are ex- 
amined, it will be found that the tendency to reverie and 
subjectivity has long existed. The same mental concepts 
and ideas recur very frequently, and the range of thought 
and reflection is limited. Thoughts are not projected to 
persons and things without, but revolve about the ego ; or 
if they become occupied with objectivities, all is considered 
in reference to ulterior relations to self. Slight occurrences 
become magnified in importance as they become absorbed ; 
elements are added to them by the imagination from time 
to time, so that what was a mere conjecture soon becomes 
a certainty. In proportion as object-consciousness becomes 
faint and infrequent, subject-consciousness becomes more 
pronounced. This stage frequently covers months and 



208 LECTURES ON MENTAL DISEASES. 

sometimes years ; the individual being regarded as singular 
and somewhat abnormal and perhaps unwell, before finally 
his condition becomes apparent by the commission of some 
public act which renders it beyond a doubt. 

The essential element in the disorder of mental activities 
in those cases which reach asylums is that of delusions. 
This, however, has its basis in, and arises from the previous 
existence of imperative concepts and insistent ideas. Con- 
cepts and ideas which may flash into the sphere of con- 
sciousness become colored and their importance magnified 
in consequence of the supersensitive condition of the 
centres through which they become intellectualized, though 
the individual has not the slightest suspicion of this him- 
self. His reflections upon these exaggerated ideas which 
arise in the mind soon develop them into more than 
ideas ; they receive reinforcements from other mental 
experiences, and ere long become converted into real 
delusions. Anatomically considered, the various areas of 
the brain through which excitations pass become mor- 
bidly sensitive ; consequently, they offer less resistance to 
impressions which seek to pass through them and func- 
tionate unequally and irregularly, thus giving rise to 
different forms of mental activities, according as they pass 
to the cortex or the sensory centres. 

Delusions may frequently arise from the presence of 
hallucinations of one or more of the special senses, and, 
when this is the case, the delusion derives its character, 
in some degree, from the function of the organ or sense 
affected, whether it be that of hearing or general sensation. 
For example, when the hallucination relates to the sexual 
organs which become unduly excited, patients may believe 
that they have intercourse with angels, or with persons 
who enter their rooms at night in the most mysterious and 



PRIMARY DELUSIONAL INSANITY. 20O, 

impossible manner. They believe they have visions of the 
Virgin Mary ; that they hear voices of approval which 
come from her, for conduct which would otherwise be 
criminal. They hear commands to preach the word of 
the living God, because they have been so highly favored 
by these visits of celestial beings, etc. 

Hallucinations of general sensation are very common, 
and in many cases form the basis of delusions. It is 
often difficult to distinguish between hallucinations and 
illusions ; that is, whether the sensations are purely sub- 
jective, or whether they have a basis in an irritation of 
the peripheral terminations of the nerves, as in cases of 
chronic alcoholism. In a considerable number of cases 
there doubtless does exist a true sensation of an irritative 
or painful character, and patients endeavor to relieve it by 
the use of frictions, or ask for remedies for the purpose. 

These abnormal sensations are frequently complained of 
in the spinal cord and the lateral surfaces of the back. 
Sensations like an electric shock shoot up and down the 
spine and over the scalp. The rooms which are occupied 
become filled with electric fluid at night and patients 
request to have them changed for others. The brain and 
whole nervous system may be believed to be illuminated 
by it, so as to be seen by others, leading to the desire to 
remain isolated, and a refusal to go into public places. 

When the genital organs become the seat of hallucina- 
tions, the patient may complain of having been castrated, 
or in some way deprived of sexual capacity through the 
evil machinations of some fanciful enemy. Women believe 
that they are pregnant, or that they have been abused 
during sleep. 

The delusions may be those of exaltation or pseudo- 
depression and persecution. The latter are the most 



2IO LECTURES ON MENTAL DISEASES. 

frequent, especially during the earlier periods of the dis- 
ease. The ordinary occurrences and experiences of 
every-day life are regarded as having some special connec- 
tion with, or relation to, these delusive beliefs, and are 
interpreted according to the depressed or exalted state of 
mind. 

The memory is not impaired during the earlier stages, 
but, on the contrary, is remarkably good. The patient is 
able to recall and state in a clear and connected manner his 
experiences which have arisen in connection with the hal- 
lucinations, and he reasons about them in a more or less 
logical manner. The line of thought is quite connected, 
the order of ideas and concepts sequential, and the con- 
clusions are frequently not unreasonable. The contrast 
between cases of other systematized forms of insanity and 
that of the delusional form, in this respect, is remarkable. 
Instead of the impressions and hallucinations being of a 
temporary character and often changing, leaving little or no 
remembrance of them, they remain and present a vivid 
residuum in consciousness during a considerable period. 
The patient is often able to present, even in minute detail, 
the nature of his experience, and also that of the delusions 
of persecution to whfbh they give rise. 

As illustrating this and other features of the disorder, 
the following case, which was under my care during 
several years, will be in point. The preliminary statement 
has been condensed from the one he gave me himself, 
and I present his letters verbatim et literatim, as they 
were sent to me* simply suppressing names of persons, 
dates, etc. : — 

Case i. — F. A. O., aged twenty-nine, of light complexion, 
sandy hair, medium height, thin in flesh, and of a neurotic 
temperament, was admitted in 188- His father is excit- 



PRIMARY DELUSIONAL INSANITY. 211 

able, quick in temper, and highly nervous ; his mother died 
while he was young, of some chronic disease. 

About five years prior to his admission to the Retreat, 
he went to Europe, and had some vague plans in reference 
to studying in Germany, but finding it disagreeable, and 
having some rheumatism, he went to Paris and spent his 
first winter there ; he was much alone and had no acquaint- 
ances, and found it very unpleasant. The next summer he 
traveled about Switzerland and Germany, and spent the 
two succeeding winters in London, attending lectures on 
mathematics and philosophy. He appears to have spent 
the next year in wandering about Europe rather aimlessly, 
and finally concluded to spend the winter in Southern 
France. While at Marseilles he began to be troubled with 
sounds at night — thought he was watched by somebody, 
and that his landlord was anxious to get him out of his 
lodgings. He left in a short time for Nice, where he took 
lodgings, and soon got into trouble because he had no 
money with which to pay for them. He thought that a 
very disagreeable woman was hired by his landlord to dog 
his steps whenever he left the house, and to look into his 
windows when he was indoors. He was frequently roused 
from his sleep in the night by the voices of persons in the 
hallway and near his door. Sometimes they demanded 
admittance, which he always refused, and then left for the 
night. He finally received his remittance, settled his bill, 
and secured another lodging. His persecutors, however, 
followed him, and after he had retired for the night made 
some disturbance at his door, but then left. He fell asleep 
and after awhile was aroused by their reappearance and 
knocking at his door. He heard a woman on the balcony 
near his windows tell him to get up and load his revolver, 
which he proceeded to do, and while thus engaged his 



212 LECTURES ON MENTAL DISEASES. 

room was entered by two policemen through the apart- 
ments of another lodger, and he was taken to the police 
station with all his luggage. A magistrate examined him 
about 10 o'clock in the morning, and finding nothing 
against him, let him go. He immediately took passage for 
Genoa, arriving there at about 1 1 p. m. He secured a room 
at one of the hotels and retired. At about 4 o'clock he 
awoke hearing a woman's voice telling him to get up and 
dress, that some one was about to try to rob him. He at 
once dressed and took down a clothes-rack with which to 
defend himself, and waited until morning. He said some 
one whom he had formerly known was putting up persons 
to do all this to spite him. He at once left for Pisa, and 
while on the way an old man in the coach kept buzzing in 
his ears and trying to turn his eyes crossways. After 
arriving in Pisa, he experienced the same annoyance as at 
other places. In short, he wandered around for weeks, 
over Europe, trying to get away from his persecutors, the 
buzzing in his head, and from the danger of robbers. 
Finally, his father found him in Paris, and, after considerable 
hesitation on his part, in consequence of his suspicions and 
hallucinations of hearing, succeeded in inducing him to 
return to his own country. 

At home he conceived the idea that his system was filled 
with electricity, which greatly annoyed him, and after 
spending several weeks in arranging and re-arranging wires 
to carry it off, and threatening some of the members of his 
family as the cause of his annoyances, he was brought to 
the Retreat, where he has been for the past five years. 
During this period he has suffered from hallucinations of 
hearing and smell, illusions, delusions of persecution, and 
abnormal sensations in the brain and various other portions 
of the system. 



PRIMARY DELUSIONAL INSANITY. 213 

During the last two years he has been frequently at his 
father's house, and when there has a room which he occu- 
pies. He is still affected with the delusion, when there, 
that the room is filled with electricity, and when at the 
table will sometimes throw down his knife and fork on the 
table, and looking up to the ceiling, exclaim, " There ! they 
are at me again." He has written me many letters at dif- 
ferent times, describing his perverted sensations, illusions, 
and delusions, and I herewith introduce some of them in 
the order as to time in which they were written : — 

Retreat, January 11, 18 — . 
Dr. Stearns : — 

Dear Sir. — I am not doing as well as should be expected from 
the large amount of complaint that I have been making of late. 
There seems to be some great prejudice against me on the hall, which 
is impossible to overcome without your assistance. I am taking hold 
very well, but there is great back-pressure, so am obliged to fall back 
into my old ways again. Now this opposition comes from but one 
person, and he is determined that I shall not talk at the table or at 
meals, or make any appearance in the hall, and is disposed to whis- 
per rather uncomfortable things against me. Now this person is the 
watchman, S. He claims that my uncle, Mr. G. W., has told him 
that they were in a great hurry to get rid of me, or get me out of 
existence at home, and he claims that he has the job and is deter- 
mined to put it through. His first idea is to thin me out like a shingle 
while asleep at night, and then to force some of the numerous dis- 
eases that man is heir to on me, and to end my mortal existence and 
call my story ended. Please look into the matter and have it recti- 
fied if possible, and oblige 

Yours, F. A. 

Retreat, January 21, 18 — . 
Dr. Stearns : — 

Dear Sir. — There is another strong point against S., the watch- 
man. He is trying the dastardly trick of destroying my right eye. 
It has troubled me more or less since he has been on night duty, and 
I have spoken to Dr. P. several times in regard to it, but he has 



214 LECTURES ON MENTAL DISEASES. 

assured me that it would not amount to anything ; but now that I 
have personal difficulty with S., the trouble is increasing, and am 
afraid that some permanent difficulty like a cataract may be the 
result. There is a largeness and a blueness of the sight which seems 
to be increasing, and I also have trouble in reading ; the eyeball 
twists and jumps about as if mad. It is very strange how the mag- 
netism can take hold of such a sound body as the eye. I should 
think that you would advertise to straighten cross-eyes. If you can 
pull them out of straight, why can't you do the opposite and straighten 
them when crossed ? 

Do please stop this abuse of S.'s. I am trying my best to obtain 
your consent to board at home once more, but the fellow is putting so 
many stumbling-blocks in my way that it will be impossible until they 
are removed. 

Yours, F. A. 

Retreat, February 2, 18 — . 
Dr. Stearns : — 

Dear Sir. — I wish that you would look into my case a little. I 
am falling back so fast under S., the watchman's, abuse that I am 
absolutely sick ; my ears are out of order, and I am buzzing again at 
meals. I cannot think without attracting the attention of the whole 
neighborhood. My tongue is also drawn back out of shape again, 
freeing my tonsils, which your heavy bromine influence sways back 
and forward, making it difficult to speak or talk. S. is so saucy and 
ugly that I am afraid of him. My brain is drawn up off from the 
centres, thus making clear, free thought impossible. Why is it that 
you force such a scab like S. to feed on Parlor Hall fare ? Do please 
free the Parlor Hall from the curse, and oblige 

Yours, F. A. 

P. S. — S., to follow up his formula, orders some wearing or flesh- 
consuming influence to act upon me when asleep at night, that tends 
to hold me down in size and weight. I should, under this free and 
easy life, be growing in size of frame and fat, but I hold about my 
old weight. Why can't the influence be changed into a tonic and 
flesh-forming one ? I have done nothing to merit such abuse, and am 
confined only for being a little saucy and free at home, and can see 
no sense in holding one down so long. Please look into the matter 
and have it changed, and oblige 

Yours, F. A. 



PRIMARY DELUSIONAL INSANITY. 215 

We have in the above letters an example of how com- 
pletely the personality may be overwhelmed by the strange 
concepts, dominant ideas, and consequent delusions, which 
would be utterly repugnant to it in a condition of health. 
There is no limit to the peculiarity and hideousness of 
the idea as it becomes projected into the sphere of con- 
sciousness, and really with only the slightest ground for its 
existence except subjectively. The dominant idea, as will 
hereafter be seen, is that of returning to his home to live. 
He has spoken of this often, and yet finding that he cannot 
obtain permission to go, begins to cast about for the oppos- 
ing influence. The regular attendants on the hall are very 
friendly with him, and he with them ; but he only occa- 
sionally sees S., the night-watch, and usually at the tea-table. 
The latter is a rather quiet, reserved sort of person, and 
says but very little to any one except those for whom he 
has occasion to do something. Now this very circumstance 
of silence seems to suggest the idea that S. may, after all, 
be the person who uses an influence against his return 
home. From this as a starting point, there arise other 
allied concepts, and as they become modified through the 
morbid character of reflection, and the consequent semi- 
delirious state of the mind, they assume all the importance 
of realities. He construes S.'s silence, or some look or 
word he may chance to speak to some one else, as relating 
to him ; he suspects him of dislike, and then of using 
some secret influence against him. He connects him with 
his perverted and semi-painful sensations as their cause, 
and the idea becomes transformed into the delusion that 
he is endeavoring by some secret trick to infect him with 
disease, and thus end his story. 

In a similar manner he proceeds to connect other sensa- 
tions and concepts with something he has observed, or 



2l6 LECTURES ON MENTAL DISEASES. 

thinks he has observed, in the conduct of S., when in reality 
there exists not the slightest ground for such a connection. 
The abnormal sensations become illusions. He has some 
abnormal sensations about one eye at times, and has occa- 
sionally spoken of it to me. Now while he regards S. as 
his enemy, his appearance or the sound of his footstep as 
he passes his door in the night gives rise to the suspicion 
that he is the secret cause of the difficulty with the eye, 
and hence that he is using a malign influence to destroy 
it, by twisting it out of axis, or causing it to protrude from 
the socket. He is not gaining in flesh as he thinks he 
should under ordinary conditions, and this leads to the 
belief that it must be due to some strange influence brought 
to bear on him at night by S. when he is on his rounds 
through the hall. 

At times, with the aid of assurances by the physicians, 
he is able to correct the false logic of his mental opera- 
tions, but when left alone it tends to constantly reappear, 
and his imagination lends food to the delusion, which 
increases upon whatever is supplied to it in the way of the 
most casual occurrences, until after a while the whole 
sphere of thought becomes absorbed and influenced by it. 
Every word he may hear, and every occurrence he observes, 
has some secret reference to him, and is designed to his 
prejudice. 

The following letter indicates the manner in which the 
delusion increases as the sphere of thought in relation to it 
enlarges in extent, and it begins to dawn upon him that 
others are entering into the conspiracy to prevent his return 
home. He remembers some word spoken by his step- 
mother, or which he imagines he has heard her speak, which 
suggests that she may be using her influence against him. 
The idea becomes magnified and dominates, for the time 



PRIMARY DELUSIONAL INSANITY. 2\J 

being, the course of his thought. If she is against hhn, 
then she may be abusing his father, whom he at once 
pictures as a sadly persecuted individual. But if she exer- 
cises a malign influence over himself and father, why may 
she not do so over others — the neighbors, the pets, and the 
domestic animals about the house? The suspicion becomes 
a conviction. Again, if this person can and does exert so 
baneful an influence at home over those whom she meets, 
why may not other women whom he occasionally sees about 
the Retreat, but with whom he never speaks, do the same. 
This suggestion also becomes a conviction, and he at once 
projects the female attendants into the grand conspiracy 
which is now in operation against him. 

The hallucinations of general sensation which affect the 
spinal column so vividly seem to him to be like the effect 
of electricity. He is aware that there is an instrument or 
" Machine " for the use of this in the Retreat, which leads 
to the suspicion that I am using it on him in the scheme 
which is being enacted against him. His thoughts become 
voices which he hears from persons whom he may pass 
in the street, who look askance, and speak aloud about 
the very subject of his mental operations. Finally, the 
explosion of his train of suspicions and delusions finds vent 
in the letter which he addresses to me : — 

Retreat, February 3, 18 — . 
Dr. Stearns : — 

Dear Sir. — I have got one very important point for you to look into 
before much advance can be made in persuading father to take me 
home to board again. This point is the great power that Mrs. J. pos- 
sesses in venting her spite whenever she will, even to the death of the 
victim, by the aid of your powerful electrical or magnetic machine. 
She intimidates father to such an extent that he does not oppose her 
in any way whatever, and carries the abuse to an excess in my case, 
delighting to torment me or put me under a ban, when with her in 
19 



2l8 LECTURES ON MENTAL DISEASES. 

public, by some of your powerful narcotic influence, or some slur pro- 
duced by your lunacy abuse, as when with her in the house or cars, 
or in company. Now, has not this abuse been carried far enough ? 
You spoke to me of its being unpleasant at home ; but it is all caused 
by your women here at the Retreat abusing me at a long distance 
while at home, and by her request. * * . * * Father would have 
encouraged my coming home long ago, if he had not been so fear- 
fully intimidated by her with the aid of your machine. As your 
women follow her so closely, and vent out her spite in any direc- 
tion whatever, by terrible punishment. For example, the case of our 
neighbors, the Miss M., two old maiden ladies living in a quiet way 
just opposite to our house. They were both troubled a little with 
eyes, and Mrs. J. kindly agreed to bring over the morning paper and 
read to them the news. Well, this was kept up for some years, or 
until the ladies became very tired of it and hinted strongly for to give 
up the practice ; but she persisted, when one of them became a little 
saucy, which provoked her, and she swore vengeance. Well, the end 
of the matter was that the abusive one became almost totally blind, 
and finally paralyzed, and was held in this condition until she died. 
You may laugh at this, but it got to be quite a scandal in the neigh- 
borhood, as the maiden ladies were not at all afraid to howl at the 
windows that they did not want her to come, etc. 

Now, it is this same thing that intimidates father. When he is 
inclined to give me a trial, she takes right hold of him and follows it 
up, and absolutely makes him keep me here. As, for instance, last 
summer he told me to find some employment and go to work. I 
made an engagement with a Mr. W., but he was absolutely afraid of 
her, and consequently refused to allow it. He was, and is now, very 
desirous of having me earn my own living, but dares not oppose her, 
as he is afraid of her, and your women would kill him, I am confident, 
to please her. Now, why can't this abuse be stopped, and he be per- 
mitted to think freely and to use judgment in my case ? Again, your 
women are most too free in talking and posting them at home in 
regard to my affairs here ; they howl out insulting things that preju- 
dice my father greatly, and you, yourself, are too familiar and sarcastic 
there. Now, if you will order your women not to follow her whim, 
you will greatly benefit the male members of our house. I am very 
polite to her in every respect and study to please her. Now, do not 
call me insane for writing you this, as it is a very grievous point, but 



PRIMARY DELUSIONAL INSANITY. 2I9 

say a good word, and help us by stopping this intimidation and abuse 
of several male members of the community by one female. I do not 
want it possible when any matter of importance comes up that I am 
interested in, and must talk and know something, for her to have the 
power, by a mere thought or motion, to draw down upon me the 
strength of your powerful narcotics or to cast a slur upon me by your 
lunacy nonsense. I consider that I have been punished enough by 
this long term of imprisonment, and have earned an entire exemption 
from all your lunacy abuse. It would ruin me completely if she were 
permitted to abuse me while in the Probate Court, etc. 

Now, please do not make this letter in any way public, as it is for 
your eyes alone. I do not want any trouble at home, nor to be fol- 
lowed up there as S. has me here at the Retreat. Now, what I want, 
and it is the whispered request of father, that you order your women 
by a written note to them, not to follow her and avenge her little 
spites, and put people under a bane to please a partially insane 
woman, as she absolutely ignores human suffering and life. She is 
constantly striving to distress and injure some animal and make it 
suffer. We can keep nothing in this line. Your women have killed or 
stoned to death at her order the following list of live stock belonging 
to us : A little pet terrier that father valued highly ; a carriage horse, 
two cats, and two or three canary birds. J. is sick as soon as he enters 
the house, and father is in constant fear of his life. She has murdered 
Miss M., and was the cause of the death of brother F., and is the 
cause of the ill-health of her mother. She torments and intimidates 
our family to such an extent that father was obliged to confine me in- 
doors to save my life. The prevailing influence at home now is 
cathartic, with a peculiar chill that keeps father constantly in misery. 
Now, all this misery and trouble can be stopped by an order from you, 
which please give. These statements are for you alone, and are true 
in all respects. Please favor me, and do not prejudice me at home, as 
all is very pleasant and agreeable. It is only the underhanded 
nonsense that should be stopped. 

Yours, F. A. 

P. S. — This is written very carelessly, but please excuse. 



LECTURE XI. 



PRIMARY DELUSIONAL INSANITY. (Concluded.) 

The Cause of Delusions may be a Super-sensitiveness of the Spinal Cord — 
Tension of the Mental State — Letter — Mind-jreading — Letter — Case — No 
Transformation after Seven Years — Intensity of Hallucinations in Some 
Cases — Hallucinations of Smell Most Frequent in Cases having a Sexual 
Origin — Case 2 — Letter — Case 3, Illustrative of its Slow Development 
— A Large Degree of Mental Activity Exists for Many Years — The 
Character of the Hallucinations may Indicate a Sexual Origin — Letter 
— In Many Cases a Transformation from a State of Depression to one 
of Confidence and Partial Excitement Occurs — Persons Become the 
Owners of Vast Estates — Kings, Queens, Illustrative Cases — Peculiar 
Writing, with Translation — Cases in which the Delusions have been from 
the First of an Exalted Nature — Case — Prognosis — Recovery Sometimes 
Occurs in Acute Cases — Remissions of Considerable Duration — Treatment. 

In primary delusional insanity, delusions of persecution 
are frequently the outgrowth of hallucinations and illusions 
of general sensations, and often a cerebro-spinal super- 
sensitiveness which arises from the habit of masturbation 
or uterine disease is present. There exists no doubt that 
the patient whose case was studied in the previous lecture 
had been a masturbator for some time before the develop- 
ment of insanity. This will in some measure account for 
the peculiar character of the conditions demonstrated in 
the following letter. The letter also indicates how fully 
the writing of the former letter appeared to relieve him of 
the state of mental tension into which his mind had passed 

220 



PRIMARY DELUSIONAL INSANITY. 221 

in consequence of the morbid concepts and ideas which 
had occupied it. 

Retreat, February 8, 18- 
Dr. Stearns : — 

Dear Sir. — I have still another complaint to make to you, and it 
should be done as soon as possible. My list of regularly systemized 
abuse is large, I know, but it is not complete until the following is 
added. The right side of my head is inclined to swell itself out, or 
to have that feeling, and to be clearer than the left. The eye upon 
this side is inclined to follow in this general run, and my ear is very 
sensitive. I should feel sorry to find some morning that this unruly 
side had got to be much larger than its companion, and I think this 
change would not add greatly to the beauty of my face. Now, can't 
this nonsense be stopped ? I have put up with much in this line, but 
am afraid that if it be continued, possibly a permanent set may be 
produced which would greatly disfigure my face. Please look into 
the matter and have it stopped. Now please do not let my letter to 
you Saturday in regard to this underhanded meanness at home make 
you nervous at all. I wrote you to let you know the conditions of 
things there on the sly, and to help father. Outwardly we are in 
perfect harmony and friendly, and unless you show it and make a 
disturbance, I shall be able to arrange matters with father soon, and 
return home with the best of feelings. Now please help me in this 
endeavor to make father's life more comfortable. I have written to 
you from the kindest of feelings toward my father, and to relieve him 
from a scourge, and to prolong his life. Now please look kindly 
upon it and oblige 

Yours, F. A. 

In the next letter he describes that peculiar condition 
which some patients occasionally are affected with, namely, 
that of mind reading ; they think that physicians often, 
and sometimes attendants or friends, have the power of 
affecting the brain in such a manner as to render its mental 
operation visible to others. Their very thoughts are read 
by persons whom they may pass in the street, and may 
become converted into voices which they hear from a 



222 LECTURES ON MENTAL DISEASES. 

distance. These persons are heard announcing to others 
various intentions and purposes ; they blow fumes of noxious 
gases or chloroform through the windows or doors of the 
room at night ; they injure their genital organs and render 
them useless ; they put poison in their food, and do many 
other things to render their lives wretched, all of which is 
interpreted by patients as a part of the general plan of 
persecution which is being carried on against them. Our 
patient will explain some of his experiences in this respect 
in the following letter : — 

Hartford, January, 15, 18- 
Dr. Stearns : — 

Dear Sir. — There is one point yet in regard to the treatment here 
that is very aggravating and disagreeable, and I should like to have 
it stopped. There is a peculiar influence that you might call almost 
luminous which you surround the victim with that tends to make him 
transparent, so that persons near me can see the action of my different 
organs, making it sometimes very disagreeable, and especially so 
when in ladies' company with some difficulty with the bowels. And 
it is also disagreeable when applied to the head, showing up the 
action of the brain, which, if not in a good, free, healthy condition, 
tends to throw a slur upon its owner ; and again is bad if thrown 
upon me suddenly while passing ladies upon the street. I have heard 
them say several times, " What is the matter with that fellow ? Why, I 
am afraid of him." Now, if possible, I want it stopped. I see no 
sense in casting such great notoriety and prejudice against me in the 
city. It would also be uncomfortable and would destroy the confi- 
dence if you were to abuse me thus while boarding at home. Father 
would not stand the nonsense, and would confine me again. Now I 
am very desirous of freeing myself entirely from these abuses. I 
have lived here long enough, and you have entire confidence in me, 
so there can be no use of keeping the humbug going longer. I want 
to walk the streets without any of these remembrances of my lowly 
existence in a madhouse. 

This same abuse or a little different, is carried to a great extent at 
home. I am followed so closely by the servant girls at the water- 
closet as to make it uncomfortable ; this was the principal cause of 



PRIMARY DELUSIONAL INSANITY. 223 

my coming here ; they followed me so closely at night as to worry 
and aggravate me much. I am very desirous of boarding once more 
at home, so please have the abuse stopped, and direct Dr. P. to give 
me the word " GO" and oblige 

Yours, F. A. 

P. S. — I do not become clear and' smooth of head yet, and there is 
also a little impediment in my speech, and my tongue is a little stiff. 

Yours, F. A. 

The above case may be regarded as a clearly outlined 
one of primary delusional insanity of one variety, namely, 
that in which the delusions of persecutions which arise 
from hallucinations, illusions, and insistent ideas play the 
most important part. He has a good appetite and takes a 
sufficient quantity of food, but all the while looks anaemic 
and far from well. Though the disease has existed some 
seven years, it has not passed through any stage of trans- 
formation into that other variety in which the delusions are 
of the opposite nature, and which would be regarded as 
indicating an unfavorable prognosis. The fact, however, 
that the disease has so profoundly affected the whole 
nervous system, and has already existed so long, renders all 
expectations of recovery improbable. 

Patients are occasionally observed in whom hallucina- 
tions of hearing and general sensation become so greatly 
intensified that they are in continual fear and expectancy of 
death in some horrible form. Voices are heard in the next 
room, near at hand, or at a distance ; they may be clear or 
indistinct; again, other sounds may be heard, such as the 
singing of birds, the ringing of bells, the noise of machin- 
ery or of passing carriages ; and the patient will locate 
with great definiteness the place from which they come. 
They become vastly intensified at times, and issue from the 
hot-air flues which open into the patient's room. The plans 



224 LECTURES ON MENTAL DISEASES. 

which are being adopted to persecute them, and to inflict 
the severest degrees of suffering they may hear repeated 
many times over, and can even distinguish and recognize the 
voices of the several enemies who are conspiring together. 

A female patient not long since told me that she could 
distinctly hear the voices of four persons whom she had 
formerly known, who were planning to injure her. The 
leader was John White, and they were arranging to pour 
vitriol down her spine and over her head, so as to have it 
a bleeding, horrible sight, too dreadful for any one to look 
upon. Others imagine that enemies are twisting the 
lungs and heart from their natural position and turning 
them upside down ; at other times are endeavoring to 
extract the uterus or place the liver on the wrong side 
of the body ; they smell the fumes from decoctions which 
are being prepared to pour down the throat whenever 
they can be found asleep, and hence they do not dare to 
go to sleep or even to lie down until forced to do so 
by exhaustion. These terrible delusions become so over- 
powering that patients never smile, and cannot think or 
speak of anything else, and are constantly entreating the 
physician when he visits them to avert the awful doom 
which seems to be awaiting them. The impending evil, of 
which they have so long had a fearful presentiment is now 
about ready to be consummated. 

In other cases the hallucination may be limited to smell ; 
the patient imagines that some person is filling the room in 
which he sleeps with chloroform, or with noxious gases, 
and he locks and bolts the door of his room, stops up the 
keyhole and the windows, and finally insists on leaving 
home and seeking some other place, such as a shed or barn, 
in which to sleep. Hallucinations of smell are said to be 
the most frequent in those cases having a sexual origin. 



PRIMARY DELUSIONAL INSANITY. 22 5 

As illustrating the great intensity and persistence of hallu- 
cinations of hearing, which obtain in some patients, and 
the almost incredible course of action adopted by the 
persecuted victim, by means of which to escape from the 
suffering and annoyance which they entail, I introduce the 
following case : — 

Case 2. — J. J., aged twenty-one, whose parents are French, 
a student of nervous temperament and good intellect, was 
admitted to the Retreat in 187- During the preceding- 
three years he is reported as having been studious and 
livincr at home, attending the college classes, but at times 
greatly troubled by persons laughing at him when in 
church or on the street, and by the ringing of bells, and 
the rumbling of heavy wagons and carts in the street, 
while he was trying to study at home, all of which was 
done by persons for the special purpose of annoying him. 
These troubles had rather increased of late, and he had 
failed in his examinations, which greatly mortified him. 
He became depressed and disposed to remain alone in his 
room, and took to smoking; was irritable, suspicious; took 
his food irregularly, and finally broke several mirrors, and 
threatened his sisters because he thought they caused the 
noises in the street and the ringing of bells for the purpose 
of irritating him. 

His condition varied considerably from time to time after 
his admission. He was irritable, suspicious, disposed to be 
alone ; complained of the bells of the city ringing, and was 
disinclined to exert himself, and to take even a bath or 
change his linen, or take any exercise out of the building. 
He was often visited by his father, and on one occasion 
went to Boston for a few days. He got on so well that he 
was removed home for a trial ; but after a few days became 
solitary in his habits — refused to take food with other 



226 LECTURES ON MENTAL DISEASES. 

members of the family ; complained greatly of noises on 
the street, and of the sound of the church bells which he 
said were kept ringing, and was finally detected selling his 
books, with the proceeds of which he said he intended to 
go abroad. He was then returned to the Retreat. Before 
consenting to come he demanded to be taken before a 
magistrate and examined as to his sanity. He had a con- 
siderable sum of money with him, and refused to tell how 
it was obtained. He also had a passage engaged by 
steamer for England. 

After remaining under treatment for several months, he 
was again removed and traveled with friends in the West, 
but returned home alone, and immediately took passage for 
Savannah, Georgia. He said he took this step to get out 
of the sound of bells and noises. Finding himself no better 
in this respect there he took a sailing vessel for England 
and visited London, where he remained a few days. Then 
he went to Sweden, but soon left for Southern France, and 
thence to Alexandria and Cairo, where he remained two 
months. He then returned to France, and traveled through 
Germany, Prussia, Switzerland, Italy, and back through 
France to England, where he shipped as a sailor to Africa 
and back again. All this time he says he was traveling 
from one place to another, not so much to see the places 
as to get away from the persons who were persecuting 
him by the ringing of bells, and making day and night 
hideous by the noises they created for the purpose of 
annoying him. He then began to travel about in England, 
and while at one place in the southern portion was 
arrested, as he says, on the charge of an old woman, 
whom he never had seen before in his life, that he had 
stolen a sovereign from her. He was kept in a police sta- 
tion several days, and then tried and sentenced to prison. 



PRIMARY DELUSIONAL INSANITY. 227 

where his father found him, and returned him to the Retreat, 
where he has been during the last eight years, affected with 
hallucinations, of hearing, and, in a much less degree, by 
those of sight. His memory is very good, the physical 
functions are active, and at times he reads, but seldom 
writes, and is not disposed to converse with others. Indeed, 
he says he does not care for anybody but himself, but is 
entirely satisfied with himself. He says at times he sees 
objects delineated on the walls of his room, such as table 
furniture, and that these objects move about just to annoy 
him. He has never presented symptoms of excitement or 
depression. I here introduce a letter which he wrote to 
one of my assistants, which will show the general state of 
his mind at the time it was written. 



August 10, 188- 
Dr. P. :— 

Sir. — I am annoyed by persons in the trains of the Conn. Valley 
& Hartford Railroad, and by the engineers who whistle to annoy me, 
also by men who drive wagons and carts on Washington Street and 
Retreat Avenue. By persons who cause birds, crickets, and roosters 
on the lawn to chirp, sing, and crow annoyingly and disagreeably ; by 
persons living around the lawn making roosters crow to annoy me ; 
by church bells in the city rung to annoy me ; by the chapel bell ; 
factory whistles in the city in the morning at seven o'clock and at 
noon are blown to annoy me ; the lawn mowing-machines are caused 
to go very disagreeably and annoyingly; in the night I am kept 
awake and my sleep is disturbed by patients who cause the clock in 
the hall to tick to annoy me, and by persons who cause roosters and 
birds to crow and sing to annoy me. I am made to have erections 
and sometimes emissions in the night, which is done to annoy me, 
and I am kept constipated to annoy me, sometimes not having more 
than one passage in a week ; thunder is made to go to annoy me. 
Some of these annoyances continue more or less almost all the time. 
Please have them stopped. J. J. 



228 LECTURES ON MENTAL DISEASES. 

The following case is of special interest, as it illustrates 
several peculiarities in the character of the symptoms of 
primary delusional insanity. 

First. — Its slow development, extending in some cases 
over a period of many years, and attended with remissions. 

Second. — The intensifying and exaggerating of peculiari- 
ties of individual character which have been inherited, and 
which have appeared at or before the pubescent period of 
life ; and 

Third. — The large degree of mental energy and activity 
which may continue more than forty years subsequently to 
the first manifestations of the disease. The hallucinations 
were confined chiefly to the sense of smell. This is said to 
be the case more especially in those cases in which the 
habit of masturbation has existed. I find from the record 
of her first residence in the Retreat, that this habit was sus- 
pected, but nothing more is recorded in reference to it, and 
there certainly have existed no indications of the habit dur- 
ing her last residence here. It will, however, be noticed 
that when sixteen years of age she was morbidly religious, 
somewhat hysterical, and at times depressed, which, possi- 
bly, led to the suspicions recorded. 

Case 3. — " G. S. O., age about twenty-two, single, original 
disposition, kind-hearted, but self-willed and impulsive, 
cheerful and hopeful. Intellectual capacity of uncommon 
order; writes, reads, muses, and is inclined to seclusion, 
and has been so for seven or eight years ; more particularly 
for two years past ; has become wakeful at night, getting 
up and going about the house alone, sometimes singing 
and talking, and sometimes laughing and crying. Has been 
extremely sensitive whenever her will was crossed or opposed 
and had visionary religious " impressions." Became excited 



PRIMARY DELUSIONAL INSANITY. 229 

on religious matters ; thought a day was appointed for her 
to die, and when this was past, then another, and so on ; 
experienced a longing to die. She was nine years of age 
when her mother was divorced from her husband and 
became insane, and died in this condition. She was mor- 
bidly religious wrien sixteen years of age ; her health 
suffered much from irregular menstruation. " While she 
has many things in her character and disposition calculated 
to interest persons with whom she comes in contact, through 
all these qualities there is a morbid action of the mental 
and moral sentiment which foreshadows a future in her 
experience which we dread to contemplate." 

On admission, April, 1853, she did not sleep, and would 
not remain in her room all the while. Would not walk 
unless alone. Had suppression of menses, and delusions 
of apprehension ; was very obstinate ; wrote letters and sent 
them off sealed, contrary to orders ; refused to eat any meat, 
and complained of treatment ; complied with nothing ; was 
whimsical, capricious, fault-finding, irregular at meals ; 
when out walking started to walk off to the river, saying 
she had lived long enough. At times despondent, and at 
others somewhat excited. Went away for a month, and 
returned apparently quite reconciled to do so. Was sus- 
pected of masturbation, but took medicine and improved 
considerably, and finally was discharged as recovered, 
May, 1855. 

During the next twenty-five years she lived in more than 
as many places, never able to get on very long at a time 
anywhere, and could never agree with anybody except 
cats. She was very fond of these animals, and after awhile 
obtained as many as twenty ; she lived with them in one 
and another place, always fearing lest any one of them 
should get killed, suspecting and disagreeing with all with 



23O LECTURES ON MENTAL DISEASES. 

whom she had much to do, and finally secured a small 
house in the woods at a considerable distance from other 
houses, where she remained with her cats until her physical 
health became so impaired that her friends interfered and 
removed her again to the Retreat. 

At the present time she has been under observation six 
years. It would be difficult to present a picture covering all 
the principal features of the psychical life of this person during 
this period. One of the more prominent traits of character is 
that of selfishness. The thought of self and what may be done, 
or neglected to be done, for or against her wishes, and sup- 
posed interests, absorbs her mental energies and covers the 
sphere of mental activities. She listens to all that is said and, 
observes all that is done with reference to its bearing upon 
herself, and at times construes the most harmless remarks 
into some meaning which would not for a moment bear the 
light of ordinary construction. She desires to be odd and 
eccentric in appearance, and, when spoken to about it, says 
it indicates individuality and character; that she does not 
wish to be like other people. She wears constantly a pecu- 
liar turban or headgear, she says, to prevent attacks of neu- 
ralgia, from which she claims to suffer very much. She is 
never shy or reserved, but, on the contrary, courts atten- 
tion ; is quick at repartee, and is especially pleased to have 
persons inquire after any of her literary performances. She 
complains much of unpleasant odors, and claims that the 
air of the hall is laden with them ; that the mucous surfaces 
of her throat and lungs have been ulcerated, and that she 
suffers the most excruciating agony from being obliged to 
breathe this air day after day. Menstruation has ceased for 
several years, and there appear to be no perverted sensa- 
tions in connection with the sexual system, but she has on 
several occasions suspected the physicians of proposing 



PRIMARY DELUSIONAL INSANITY. 23 1 

improper sexual relations when talking with her, and also 
says that they are having criminal relations with the attend- 
ants ; when asked for her reasons for such an opinion, she 
says they would never favor these persons as they do except 
there existed such relations. She remains much in her 
room, and rarely associates with or is interested in either 
patients or attendants ; is irritable, and becomes excited if 
her wishes are not complied with, using the most abusive 
language. Has perverted sensations, and says she cannot 
sleep either in summer or winter except under eight or ten 
pairs of blankets. Will not take food at the table with 
other patients, and claims that she must take food only at 
irregular intervals ; is constantly smuggling articles of food 
to her room, and then throwing it out of her windows that 
cats or dogs or the birds may get it. Will not take 
medicine prescribed for her supposed ailments (neuralgia, 
ulcerated lungs, etc.), but is constantly entreating to be 
permitted to have some nostrum which she may have seen 
advertised in the newspapers, and if denied becomes most 
abusive, accusing the physician of inhumanity, and de- 
nouncing all who have anything to do with the Retreat as 
unchristian, unprincipled, heartless scoundrels, and the Re- 
treat as the abode of fiends, who will ultimately inhabit the 
innermost circle of Dante's hell. 

Her memory is excellent ; her psychical activities are large ; 
she speaks and writes with great rapidity, and covers pages 
with words of vituperation and calumny toward all who have 
any relations with her. At other times she becomes agreeable 
and will converse in the pleasantest manner, often quoting 
from authors whom she read a great many years ago. I here 
introduce a specimen of one of her letters to me relating to 
odors of which she has complained during the last twenty 
years, and which indicates how entirely the mind may 



232 LECTURES ON MENTAL DISEASES. 

become clouded, confused, and overwhelmed through the* 
form of the hallucination, which for the time being is so 
intense : — 

Go be where I have been, 

Go feel what I have felt, 

Go see what I have seen, 

Go smell what I have smelt. . 

Retreat odors, besides their undertone of revolting-, concentrated 
stench, the peculiar suggestion of which is insanity, and incarceration 
behind heavy, impervious walls (impervious to pure air, I mean) and 
wood work of nearly sixty years' impregnation therewith, have also 
another threefold injuring character, alternating between human 
excrements, vomit, and matters from a sore, respectively, one or the 
other ever being in the ascendency, but oftener all three forming an 
effluvia that ought to be termed, from its being peculiarly distinctive 
of the place and excruciatingly fetid, "Odor de Insanity." I have 
sometimes thought that the reason those in authority did not do or 
have something done to banish and antagonize it, if possible, was be- 
cause they sought thereby to lower the moral tone of attendants and 
patients, and keep their poor patients half sick, and so make the pos- 
sibilities of which these dens of torture so readily permit more easy 
of accomplishment ; for I fully believe that voluntary filth and putrid- 
ity and vice and cruelty are a very harmonious trio to each other, and 
hail fellows well met. Swedenborg says that hell smells like human 
excrements, or something to that effect, and Dante describes the ap- 
proaches to some of its infernal corridors and descents in very similar 
terms, so that we may very safely conclude that, approved, permitted, 
coinciding with the Prince of Darkness in this respect, is no other 
than a suggestion and instigation of his, and works right in the line 
of his most demoniacal propensities, for "cleanliness is next to 
Godliness " in more than one sense, I fancy. One great cause of the 
extreme repulsion and instinctive shrinking that odors of the Re- 
treat, different from all others ever experienced, excite in my own 
mind, is, besides, their peculiarity, morally and physically defiling, 
permeating, non-obliterating tendency, fearful beyond telling; but 
besides this, I say, one of the greatest sources of torture to me in 
them has been that their very suggestion and interpretation and 
language and phase was torture, unearthly and fiendish malice, 



PRIMARY DELUSIONAL INSANITY. 233 

inhuman, demoniacal torture, whispering all too loudly, in a pro- 
fessedly Christian land and age, of the secret horrors, the infernalities, 
the God defying rigors and iniquities of the dark ages and the Inqui- 
sition. 

We have thus far studied the symptoms of only one form 
of Primary Delusional Insanity. The cases presented as illus- 
trating them have been characterized by hallucinations and 
primary delusions of a depressive type. These elements of 
disordered mental activities have led the subject to conduct 
consistent with delusions of suspicion and persecution. All 
of these cases have existed several years, and under the influ- 
ence of asylum life, the force and intensity of hallucinations 
and delusions have largely subsided in some of them. The 
mind remains in a considerable degree of activity, but it is evi- 
dent that the stage of weakness and partial dementia is present. 

According to Krafft-Ebing, however, a transformation 
from a state of depression and fear to one of confidence 
and exaltation occurs in about one-third of all cases. It 
may be quite sudden, or it may develop slowly, and form 
the effects of reveries and reflections upon impressions 
which reach the super-sensitive centres of the brain. 
Some paragraph read in a newspaper, a casual remark 
made by the physician during his visit, or the visit of a 
stranger to the hall on which the patient resides, may 
prove to be the exciting incident. 

An example of this transformatory process is presented 
on pages ioo and 101, in the case there referred to as 
illustrating the character of a fixed delusion. From being 
a person of humble origin, and the subject of persecution, 
she gradually became one connected with a titled family of 
England, and was only waiting a little while, when the full 
right to her proper position as to family and property would 
be vindicated in the Supreme Court of the United States. 



234 LECTURES ON MENTAL DISEASES. 

Others become kings or princes, or the sons of empe- 
rors, and are soon to enter into the full possession of such 
rights and dignities as pertain to persons so allied. They 
become the owners of vast estates and castles, or of all 
the bonds and mortgages existing in the country. 

There is a case now under my care in which this trans- 
formation has recently occurred. The case developed in 
connection with the climacteric epoch, and presented dur- 
ing about five years both hallucinations and delusions of 
persecution, though in a less pronounced degree than many 
other cases. The disease then assumed a new form. From 
a state in which he could rarely and with great difficulty 
be induced to leave the house, where he remained several 
months in order to protect himself from his enemies ; he, 
within two or three months, passed into one in which he 
imagined that he was of the greatest importance. He 
visited stores and gave orders for large purchases of various 
kinds ; wrote out a petition to the President of the United 
States for an appointment as Minister Plenipotentiary to 
Corea, and took it to several of the most important and in- 
fluential citizens of the city to be indorsed by them; 
appointed the day on which he was to leave the country to 
assume his duties ; invited a large number of his friends to 
join him at his expense ; entered into negotiations to charter 
a steamer for the purpose, etc., etc. It is now about three 
months since this change occurred, and when I recently 
introduced him to an ex-Governor of the State of Ver- 
mont, who was inspecting the Retreat, he at once urgently 
pressed him to join his company, at the same time telling 
him the names of persons who were to go along, and also 
the route to be followed by different members, through 
China, Japan, and India, returning by the way of the Suez 
Canal to Liverpool, and thence to America. He no longer 



The following is a specimen of writing by a patient with primary delusional 
insanity, who has been in the Retreat for nearly twenty years. She makes 
these marks, or letters, as she calls them, with great rapidity, and has covered 
reams of paper with them during former years. Of late she has written very 
little. She claims that she is unable to explain how she performs the writing, as 
it is done involuntarily on her part, except in the holding of the pen on the paper. 
Some influence, " like that of inspiration, causes my hand to do the writing." 

wv\\>.\?i ^^.Ko.tO^.srA.^^f^V^v^USS* 

^^^W^Vx^^^i^^^^^.^^, 

^^v?i^4^a.^^.v,^^>:^^.U^^,S,lx^.: <, -, v 

r»l#*«&"^>.*.£« i ;-,T,vM,v#Ui.! .^ JAvv.v 

p6^^^^^^^^^^.^f.^^^^^^«^.v^ / ^<^ 

?j4tea.H#|.TA^^^ 

{/U< ,Cii& [^n.L*-{iJt.'vU- hxit /Vvu^tv fL- iiju. f\.e.f/C~ *l^> t^jU 

c*M A-ctvL/crua 'HtA.u K*,-U <f/» (^ju,»v>j« 

/lUci-^^^*^* 1 lZA-*,'f\.t$- A*-~- !n»lu tJ/iuoU'^ /&* A*y* 

JiLt /V*/tW •»•« tf~f <L (J-Hftw tVjyt Aw« ll*. j /l^i/fu i ; » » • 

TUx. iu*yt^ " xr/ tiuc /U.^L/e > w j - Itj „ i <lc /«lw . . 



PRIMARY DELUSIONAL INSANITY. 235 

talks of being deprived of his rights or anything else ; he 
no longer seeks seclusion, or wishes to avoid his friends, 
but he feels that he has passed into new and enlarged con- 
ditions of life. 

He sees resemblances between persons whom he meets 
and people of distinction whom he formerly knew, and calls 
to mind trifling incidents in connection with such persons, 
dwelling upon them as of the highest importance. Gener- 
ally there exists a basis or thread along which he strings 
his delusions, and this is his experience in holding 
political offices several years since. He has now fully 
recovered his health, was never better in his life, and never 
better situated or qualified for the discharge of the most 
important duties of his high station. He has studied the 
character of the government, the customs and habits of the 
people to whom he is to go ; has carefully traced out the 
geographical features of the country and the location of 
the most important places, and will tell all about them 
with the utmost care and seriousness. 

During the first portion of this transitional period there 
were two or three weeks in which he was constantly engaged 
in drawing up legal papers for the purpose of suing the 
officers and directors of the Retreat, bringing forward suits 
of several hundred thousand dollars. These papers were 
all prepared with great care, and addressed to sheriffs to 
be duly served, and after awhile, finding no results from his 
efforts, he became suspicious and distrustful, especially of 
the attendants to whom he had given the papers. 

He used very harsh and opprobrious language, then struck 
one of them, and threatened to kill all of them, d — g them 
all to h — 1, as the cause of his misfortune. He exercised 
neither reason, reflection, nor common sense, began to break 
up his furniture and destroy his clothes, to spit on the walls 



236 LECTURES ON MENTAL DISEASES. 

of the hall and room, urinated on the floor, and resorted 
to all the means he could devise to annoy his attendants. 

But since the delusions of exaltation have appeared, this 
destructive tendency, and the accompanying irritable, irasci- 
ble state have passed away. He is now bland, £alm, affable, 
and condescending to all with whom he has anything to do. 

The last case which I shall present, as illustrating the 
character of symptoms, is one in which the transformation 
has taken place. So far as the history of the case indicates, 
however, there has not existed so profound a state of perse- 
cution as has existed in the other cases detailed. 

A. H., aged twenty-seven, single, a farmer ; a Seventh- 
day Adventist; has had a common-school education. His 
father was eccentric and his mother insane late in life. He 
is quite ingenious, something of a mechanic ; rather stu- 
dious and thoughtful, and has invented some kind of a 
valuable machine ; is suspected of masturbation. On ad- 
mission it was stated that he had been peculiar for two or 
three years ; had written a letter to his sister with blood 
from his arm ; and had peculiar ideas about the Bible and 
inventions. He believes that he has been sent by God to 
preach, and has been going about from place to place for 
this purpose, carrying with him a two-edged sword, and 
wearing a fantastic suit of clothes. He has also distributed 
tracts in regard to himself as a prophet and " the man on 
the white horse " in Revelations. At times thinks he is 
persecuted ; sold some property some time ago, and since 
has the idea that he has been defrauded in the transaction ; 
spends a large amount of money on trifles ; has threatened 
to kill several persons, his own sister among the others ; 
and, a short time before his admission, was arrested and 
locked up in jail for throwing his sister's clothing out of 
the windows and threatening her. 



PRIMARY DELUSIONAL INSANITY. 237 

He came with a self-satisfied, pious expression of coun- 
tenance, and with a Bible under his arm, and emphati- 
cally denied that he had ever displayed violence toward 
any one, but says " he preached the Gospel and dis- 
tributed tracts," and that this was what got him into 
trouble. He controls himself and says that he is aware 
that he is eccentric, but derides the idea that he is insane. 
He says he carried his sword and adopted the peculiar 
costume to attract attention, and it proved " a powerful 
agency." He claims that his sister and her husband 
ill-treated his mother, and justified his treatment of her 
on this ground. After a residence of some days in the 
institution, he became very talkative, scouted the idea of 
being insane, and said the joke had gone far enough. His 
religious experience had been such that he was called upon 
to make it public. He knows more about the Bible than 
any one else in these degenerate days, and by his careful 
study is better qualified to treat the Scripture than any 
divine ; spoke of the rottenness and hypocrisy of the 
churches, and claimed that there was no good in them ; 
claimed that there were immoral women in them, and that 
four such had invited him to bed with them, and exposed 
their persons to him. When asked concerning his belief, 
and whether his conduct at home and in the streets was 
not such as to cast doubt on his sanity, he replied, in an 
injured tone, that martyrs in all ages had been persecuted 
for their beliefs ; that he had been persecuted and hounded, 
and that he could prove from the Scriptures who and 
what he was ; and with a triumphant expression of coun- 
tenance turned to the forty-ninth chapter of Genesis, 
eigth and tenth verses inclusive, and read them. He 
claimed to be the Shiloh referred to. When asked why he 
thought himself the Shiloh, he turned to the nineteenth 



238 LECTURES ON MENTAL DISEASES. 

chapter of Revelations, fourth verse, and said therein was 
set forth the reason why he wore clothing of bright colors, 
as he was the person referred to. To prove this he turned 
to the second chapter of Revelations, twentieth verse, to 
the end of the chapter. He said the adulterous woman 
had been shown him in a vision sent him by the Lord about 
one year ago. He was also at this time shown a book, 
the edges of which were bordered with gold, and also a 
number of other things. The angel of the Lord told him 
he was Shiloh, and told him he was Jacob ; cited the fourth 
chapter of Isaiah, first to fifth verses, as confirmatory of his 
vision about the woman, and then read from the first to the 
seventh verses of the eighty-third chapter of Isaiah, as an- 
other reason for wearing red clothing. Later on he became 
irritable, and called himself a martyr, and spoke of being 
persecuted for righteousness' sake. Spent much of his 
time in reading and commenting upon the Bible and his- 
torical sketches relating to Bible countries. After a year 
he became rather less irritable, and began to write love- 
letters to any females whom he might chance to see. I 
here introduce one to show the consecutiveness of his 
thoughts, as well as their tendency : — 

" Marriage is Honorable." 

God is love. Oh, pretty Mary — why should I hesitate longer to 
ask you for your pretty hand, when you have told me in actions 
which speak louder than words that you would give it to me willingly ; 
will you, pretty one ? Oh, how sweet it would be to have it magically 
twine around my neck in holy love so pure, so sacred. Oh, so an- 
gelic. Oh, what an angel companion you would be to me, helping 
me to publish salvation, and to spread knowledge to a people in 
darkness. A world in darkness made so by many preachers or pas- 
tors ; see Jer. 12, 10 ; please write me a few lines, Mary, please do. 

This letter was addressed to one of the employees in the 
kitchen, and for several months he continued to write and 



PRIMARY DELUSIONAL INSANITY. 239 

address foolish and improper letters to various employees. 
He then changed and became more irritable and profane, 
and would utter curses on all those instrumental in detain- 
ing him. Claimed to be King David, and said his time 
would yet come. He would get revolvers and two-edged 
swords and exterminate his enemies. A few months later 
he wrote to the assistant physician as follows : " I believe 
we have reached that point in the time of prophecies that 
through the testimonies we may see the effect of every 
vision. The great day of deliverance is at hand, the day 
of trouble is at hand. Na. 1st, and 7th, Dan. 12th 1st. Is it 
insanity to believe this and proclaim it. How is the process 
of deliverance to be effected ? Is it not to put on the gar- 
ments, the beautiful garments, to represent one's strength. 
See Isaiah 52, 1-8, Na. 2, 3." 

Prognosis. — After the transformation has taken place, 
periods of depression and suspicion may return, but they 
are generally of short duration. When the primary condi- 
tion is one of exaltation, it does not become transformed 
into one of persecution in the same manner as that of per- 
secution does into one of exaltation. The prognosis is 
always unfavorable after transformation has occurred. In 
my own experience it has been unfavorable in both forms 
of the disease. 

Cases of the first variety are, however, said sometimes to 
recover. When such an issue occurs, it is found to be in 
acute cases, and in those in whom the constitutional bias is 
not deeply rooted, but when the disease has developed 
mainly from accidental experiences. 

It is important not to confound mere remissions with 
recoveries. Periods of considerable length sometimes 
occur during which the intensity of the delusions is greatly 
modified, and the patient may appear to be far on the road 



24O LECTURES ON MENTAL DISEASES. 

to recovery. Such periods have existed in both the first 
and third cases detailed above, and it has seemed to friends 
as if they were nearly or quite well. But they are generally 
of short duration, and from some slight cause, such as a dis- 
appointment, or a failure to secure what has been expected, 
or some trifling bodily illness, the old delusions suddenly 
spring into new vigor and activity. Not very unfrequently 
the patient succeeds in concealing his delusions and hallu- 
cinations for a considerable time, especially when by so 
doing he expects to gain some desired object, such as his 
personal liberty, or a permission to return to his home. 

Treatment. — This will include a residence in some 
asylum or home especially designed to secure the requisite 
care of the case, and so far as possible shield him from those 
occurrences which would act as sources of irritation and in- 
creased excitement of existing hullucinations and delusions. 
When the exciting cause has been that of masturbation, the 
bromides in large doses are often of service in allaying the 
irritation of the sexual organs and the attendant hallucina- 
tions. Opiates may also be used to relieve the sufferings 
which arise in connection with the delusions of persecution, 
and also to allay the supersensitive state of portions of the 
nervous system. Out-of-door exercise in walking or some 
kind of light employment will prove a relief by occupying 
the attention and diverting the mental activities into other 
channels. 

Those cases which come under care and treatment at an 
early stage of development, and which arise largely from 
some exciting experiences in the history of the individual, 
may sometimes be benefited by a systematic course of 
physical exercise, such as may be secured by calisthenic 
or gymnastic practice. This should be conducted under 



PRIMARY DELUSIONAL INSANITY. 24 1 

the direction of a physician, or trained attendant, with 
great regularity and persistency, during several months. 
The physical improvement secured in this way may have 
a favorable effect upon the mental state, while the change 
of thought and increased power of attention will tend to 
correct the marked character of the concepts, ideas, etc. 



21 



IvKCTURK XII. 



FOLIE CIRCULAIRE. 

Cases of Folie Circulaire Not Numerous — Impossibility of Deciding Before- 
hand whether a Case of Mania will Eventuate in Folie Circulaire — Two 
Stages of the Disease — ^Etiology — Heredity — Climatic Influences — 
More Frequent in France than in England — Symptoms— Those of 
Mania — Mental and Physical Faculties Become Excited — Period during 
which the Patient is Relieved — He Passes into the Stage of Depression — 
During the Excited Period Confusion of Ideas Rarely Exists — The 
Memory Good — A Moral Defect Present — Dress and General Ap- 
pearance — Craving for Stimulants — Painful Emotions — Forebodings — 
Desire to Remain Indoors and Frequently in Bed — The Length of a 
Full Period of Excitement and Depression — Case — Patients May at 
Times Exhibit Very Little Mental Impairment — Importance of Recog- 
nizing the Character of the Disease — Case — Prognosis — Recoveries. 

Less than one-fourth of one per cent, of those cases 
which have been admitted to the Retreat and classified 
under the head of mania and melancholia have proved to 
be cases of folie circulaire, or have eventuated in a special 
combination of symptoms which has been properly desig- 
nated by that term. When examined from a clinical point 
of view, it is doubtless of little importance whether this 
group of symptoms be regarded, as it was by most writers 
of the last generation, as one of the terminations of acute 
mania, or as a special genus of insanity. It certainly 
appears to be quite impracticable to determine beforehand 
whether a given case will prove to be one of mania with a 
sequel of recovery or chronicity, or one of folie circu- 

242 



FOLIE CIRCULAIRE. 243 

laire. It does not appear that there is any pathognomonic 
distinction between the symptoms incident to the initial 
excitement of mania which eventuates in recovery and the 
mania of folie circulaire. It is claimed that the intensity 
of the excitement is less than usually exists in mania, and 
this doubtless is true in subsequent periods of excitement, 
after the first one or two, and after the regularity of the 
two kinds of symptoms has become fully established, but 
there is no evidence that such is the case during the initial 
maniacal attack. Indeed, there can be no standard or 
measure of the excitement incident to mania, but, on the 
contrary, the largest difference is found in different cases, 
and yet with no corresponding results in the way of a 
sequel of folie circulaire. 

It has been thought more probable that a termination in 
folie circulaire arises not from any special element of brain 
character which has formerly existed, and which is peculiar 
alone to those cases in which it appears, but rather from an 
exaggerated development of that habit which is common 
to all brains, namely, a tendency toward reaction. Excite- 
ment invariably tends to produce an after period of depres- 
sion ; unusual brain activity is followed by unusual quiet 
and inactivity ; an excessive state of hilarity and happiness 
by one of dullness and depression. This physiological 
tendency toward action and reaction extends to all the 
organs of the system when in health, within certain periods 
or cycles, and tends to become established upon a morbid 
basis after experiences of mania. In a very small propor- 
tion of cases this tendency becomes converted into an 
actuality, and we have that special form of insanity which 
has been named from the peculiarity of its symptoms folie 
circulaire 

Xow whether this reasoning is based upon correct prem- 



244 LECTURES ON MENTAL DISEASES. 

ises or not, it is unnecessary to inquire further, inasmuch as 
all admit that distinctive characteristics pertain to some of 
the symptoms, when the special character of brain action 
has become established. These relate, first to the develop- 
ment of two distinct stages, which succeed each other with 
some regularity ; second, to an established periodicity ; 
third, to the special character of symptoms present in both 
stages of progress ; fourth, to an unfavorable prognosis. 
These several elements of character, and others to be 
referred to, render it appropriate to regard it as a special 
genus of insanity. 

To Falret and Baillarger belongs the honor of first 
differentiating and describing this form of insanity under 
the term of folie circulaire or folie a double form. 

-^Etiology. — Hereditary tendency toward insanity has 
usually been regarded as the strongest factor in the causa- 
tion in this special form of disease ; and it is found in 
clinical experience that nearly all persons so affected have 
such an inheritance. But this element of aetiology exists 
in a hundred cases affected with other forms of insanity to 
every one with folie circulaire ; there is, therefore, nothing 
whatever distinctive in it as a cause. And there are excep- 
tions to the general rule, one of which has been under my 
own observation, this case being a well-marked one, and 
extending over a period of many years. It is quite possi- 
ble that climatic influences are operative in rendering the 
system more susceptible and liable to take on such periodic 
changes in its mental activity. French authors refer to this 
group of symptoms as more frequent in their experience 
than do either English or American authors. Dr. Savage 
says he has had almost no experience at the Bethlehem 
Hospital in London with folie circulaire. I am, how- 
ever, inclined to regard the physiological tendencies which 



FOLIE CIRCULAIRE. 245 

exist in all the organs of the system toward reaction, and 
to which allusion has already been made, as a more power- 
ful factor of causation than any other. 

Symptoms. — The earliest symptoms present may be 
either those of depression or excitement, but in the larger 
per cent, of cases the initial period is such as attends ordi- 
nary cases of mania, that is, one of depression. This 
passes by in the usual time and manner, and the symptoms 
of mental and motor excitement succeed them. All the 
mental and physical faculties become exalted ; the memory 
becomes excessively acute, and the intellect abnormally 
active, while courage and self-confidence become boundless, 
so that no enterprise is too difficult to be undertaken and 
carried through to successful results. This period of 
excitement, however, is not followed by convalescence and 
a perfect recovery. The patient passes into what may be 
termed neutral ground, between excitement and depression, 
where he lingers for a longer or shorter period, and then 
becomes again depressed. When this rhythmic movement 
of mental states from depression to excitement, and vice 
versa, becomes fully established, we have the typical form 
of folie circulaire. 

Now, with reference to the character of the excitement 
and depression, while it may be said that in a general way 
they resemble those of mania and melancholia, the one 
alternating with the other, yet in both states there exists a 
special character of mental activity. There is a more per- 
fect sequence of thought during the excitement, and there 
is rarely any confusion of ideas. On the contrary, they are 
generally remarkably clear and well-defined, but combine 
to form judgments which are merely childish. The 
patient understands what he desires for the time being, 
what he has said, and what others have done in relation to 



246 LECTURES ON MENTAL DISEASES. 

him, and can recall it with distinctness afterward. The 
memory seems to have attained an unusual power; not 
unfrequently he is himself conscious that he is abnormally 
excited, but as the field of consciousness is so clear, and 
the memory so active, he scouts the idea that he is insane. 
The intellect appears to act along definite lines, and with a 
purpose which is appreciated for the present moment, but 
has no reference to the future, and seems to be destitute of 
the judgment and common sense which is expected even in 
a child. 

Not unfrequently a film seems to obscure the moral ele- 
ment of character, and patients who have borne the highest 
character for truthfulness and integrity become perverted 
and immoral ; they lie and deceive in all conceivable ways, 
become amorous, forsake their wives, and are constantly 
running after profligate women. They invent the most 
improbable stories about their best friends, and repeat them 
to whoever will listen to them. 

Ball reports the case of a young woman affected with 
folie circulaire who, while in the excited period, became 
pregnant, and was finally delivered of a child while in a 
succeeding state of profound depression. Some patients 
appear to take special delight in arranging their dress in 
strange and fantastic methods, and in adopting and dressing 
in old and torn garments. The more grotesque their ap- 
pearance the more satisfied they become. This is especially 
noticeable in erotic cases, who seek after bright colors. 
The attention is, however, much more easily turned from 
one object or subject to another than is common in acute 
maniacal cases. The brain centres from which the gusta- 
tory nerve arises are probably excited, and the patient 
develops a craving for stimulants of all kinds. 

There is also a special character to the symptoms of 



FOLIE CIRCULAIRE. 247 

depression. This is not so profound as in uncomplicated 
melancholia, and in none of the cases which have come 
under my observation has there existed a state of stupor. 
On the contrary, the mind continues to be active, but the 
activity is one of introspective character. It no longer 
roams over boundless fields full of impracticable projects 
or schemes of speculation, but, on the contrary, is con- 
stantly active in a severe self-recrimination and a constant 
self-depreciation. 

A limited section or limited sections of the brain have 
probably become supersensitive, and the consciousness is 
full of painful emotions, more especially because of what 
has been said and done while in the former state of excite- 
ment. This is all recalled and recounted again and again, 
and the conscience is stung with remorse, while a constant 
foreboding is present as to what may be in store because 
of the past. As if in some manner to make amends for the 
past, patients exhibit an entire change in reference to dress 
and personal appearance. They are no longer careless, 
dirty, unkempt, or negligent, but are quite the opposite, and 
are filled with wonder and horror because they have so far 
departed from the proprieties of life to which they had so 
long been accustomed. The abnormal tendency to be 
constantly on the move disappears, often as if by magic, 
and the patient who could with difficulty be satiated with 
physical exercise last week, or a few weeks ago, is to-day 
ready to remain quietly in his chair, or even in bed ; and the 
patient who a short time since was taking with a strong 
appetite and unusual relish a large quantity of food 
daily, now requires to be urged to take food at all, and is 
growing thin in flesh. The patient who was for weeks and 
months the first on the hall to be up and dressed and 
anxious to be out for a walk or a talk, has now to be urged 



248 LECTURES ON MENTAL DISEASES. 

to rise in season for breakfast, or to engage in any conver- 
sation whatever. 

The physical conditions do not appear to change so much 
as the mental in passing from a period of depression to one 
of excitement except in relation to an increase in motor 
activity. A tendency toward, and a capacity for this, is 
very marked, as is also the degree of self-confidence and 
courage for undertaking new and untried enterprises. Dur- 
ing the period of depression the patient loses flesh, is dull 
and unhappy. 

The length of time required for the nervous system to 
pass through one of these periods of excitement varies 
greatly in different patients ; indeed, so greatly that two 
cases rarely coincide in this respect. Without doubt an 
occasional case may be affected by the seasons of the year, 
becoming excited during the summer, and depressed dur- 
ing the winter. This may also be reversed in relation to 
the seasons. In other cases the whole period may not 
extend over a few days or weeks. One case has been under 
my care in which the periods of excitement and depres- 
sion each extended something over two years, and the 
transition from one state to another was very gradual. 

Another patient, now under my care, was in the stage of 
excitement when admitted, and remained so during nearly 
three years. After an intermediate state, lasting only three 
or four weeks, he quite suddenly passed into the stage of 
depression, and has not spoken one word, so far as known, 
during the last eighteen months. He is reported to have 
passed a period of three years once, before he came under 
my care, without speaking, and then became very talkative. 
Another patient passes over both the states of excitement 
and depression, with a short intermediate state, every 
month. This has continued more than seven years. 



FOLIE CIRCULAIRE. 249 

Ball mentions the case of a female in the Hospital of St. 
Antoine who was sad and depressed on every alternate day, 
and excited, talkative, and at times delirious on the inter- 
vening days. The changes attained to the perfect regularity 
of an intermittent or malarial fever. For such cases, and 
those in which the period is very short, he suggests the 
term folie alternate. He cites another case which came 
under the observation of M. Brierre de Boismont, in which 
there occurred regularly three days of depression and three 
days of excitement, with apparently no intervening lucid 
interval. 

The following case of intermittent insanity is under my 
care at present time of writing : — 

W. P., aged thirty-five, single, an entomologist by profes- 
sion, of high order of intellect, a graduate of college, has 
been affected for two years, exciting cause supposed to be 
sunstroke, has been in the Retreat more than a year, and 
with condition essentially unchanged. He remains in a 
favorable condition for eight or nine days, and then he is 
able to converse and walk about the grounds; talks with 
attendants and friends ; is interested in his specialty ; ob- 
serves the habits of insects and birds, as seen upon the 
grounds, and remarks upon them; takes long walks into 
the country, etc. On the eighth or ninth night he passes 
into a condition of partial mental stupor; does not rise in 
the morning unless made to do so ; covers his head while 
in bed ; does not reply to questions ; does not attend to his 
personal needs ; soils himself; sometimes gets out of bed 
and lies on the floor, or gets his head under a chair, or into 
a corner of the room. At other times is found with his 
feet upon a chair and the rest of his body upon the floor; 
laughs and mutters to himself, but says nothing intelligible, 
and only takes food as it is given to him. He remains in 



25O LECTURES ON MENTAL DISEASES. 

this stupid state generally from sixteen to eighteen days, or 
very nearly twice as long as he remains in his favorable 
state. The return to this, however, is not so sudden as to 
the unfavorable condition, but generally covers two or 
three days. Prior to his admission to the Retreat, he 
attempted, on several occasions, to resume his professional 
work when in this favorable condition, but never succeeded 
in working more than a few days, when he would become 
dazed, dull, and wander away. 

In a large number of cases of folie circulaire there exists 
a considerable degree of correspondence between the dura- 
tion of each of the stages, but this is not true in so large a 
proportion that it can be regarded as a rule. During one 
cycle, the excitement may cover double the length of time 
passed in the state of depression, and during the next 
cycle this may be reversed. The length of time during 
which the brain may remain in its most favorable state of 
activity may extend over only a few days or weeks, or again 
over some months, but cases rarely correspond in this 
respect more than in others. 

The degree of mental clearness also varies greatly in 
different cases, but is rarely perfect. Indeed, the condi- 
tion of mind is not easily described. Not unfrequently, 
however, patients exhibit so little of mental impairment 
that they are regarded as sane by friends, and are permitted 
to enter upon the ordinary avocations of life, and even to 
initiate schemes of a speculative character, by means of 
which they lose large sums of money. These operations 
are usually undertaken during the initial stage of one of 
the earlier periods of excitement which succeeds the state 
of comparative mental integrity, and relatives find it difficult 
to relinquish the hope of a perfect restoration which has 
arisen in consequence of a partial recovery. In view 



FOLIE CIRCULAIRE. 25 I 

of such unfortunate consequences, however, it will be ob- 
served how important it is for the physician to recognize 
the true character of the disease, and thus enable friends 
to guard against unwise courses of conduct. It will also 
be important, in view of the fact that such cases very 
rarely recover, while the reverse is true of uncomplicated 
cases of mania and melancholia. 

Baillarger refers to cases in which periods of calmness 
and lucidity extended over several years. The question 
arises whether such cases would not more properly be 
considered as those of recurrent mania. 

The following case illustrates most of the peculiar fea- 
tures of folie circulaire, and is remarkable for the length of 
time during which it continued, and for the degree of 
strength of mind exhibited by the patient until the very 
last. 

E. H., a dentist, aged seventy, married and has several 
children, was admitted to the Retreat in 1870 from another 
institution. He was reported to have been insane at times 
for many years ; his disease being attended with periods of 
marked excitement and depression ; was reported to have 
been during his excited periods disposed to enter into 
business transactions on a large scale; had made invest- 
ments in worthless property, and thus lost a considerable 
portion of his estate. When admitted he was depressed, 
and not disposed to talk except when spoken to ; had for- 
merly threatened suicide, but his wife thought that " there 
was not very much wrong with his mind." He complained 
of uneasy sensations about the region of the stomach and 
the liver, and of pain after taking food ; also complained of 
the effects of medicine, but his physical appearance was 
that of very good health. After two or three months the 
feelings of depression gradually passed away and he became 



252 LECTURES ON MENTAL DISEASES. 

cheerful and talkative ; had the liberty of the lawn ; desired 
to go to the city unattended ; said that he never felt better 
in his life, and desired to engage in doing some dentistry 
work for any one who would employ him. He soon began 
to abuse the privilege of the lawn by going to the city 
without permission, and charged excessive prices for work 
done for such of the employees as consulted him. Before 
long he became desirous of going into the country, where 
he could have more liberty, and enjoy tramping through 
the woods. He was finally permitted to go away with his 
wife, with the understanding that if, in her judgment, he 
ought to return again he would do so. 

He was readmitted in June, 1873, this time in a condition 
of excitement ; was brought by an officer, and declared that 
it was an outrage ; that he was never better, and that his 
detention was neither more nor less than imprisonment, 
that it was illegal, and brought about by a self-constituted 
court; that he should take occasion to right himself before 
the public, as his life had been blameless, and he had 
contributed large sums of money to the religious denomina- 
tion to which he belonged, etc., etc. ; threatened to prose- 
cute those who had placed him in the Retreat, and those 
who detained him, as soon as he should have his liberty. 
After two or three months he became more quiet and 
rational, and after a detention of nine months was allowed 
again to go to the country. He remained there, however, 
but a short time before he was returned, and this time in a 
depressed condition. Thenceforth he remained in the 
Retreat until his death. The condition of depression 
passed off as usual, and he gradually became active both in 
mind and body ; he took long walks in the country, dressed 
in a hunting-jacket and top boots, and would tramp over 
the hills all day if permitted, and tire out any strong attend- 



FOLIE CIRCULAIRE. 253 

ant who might accompany him. He used a large supply 
of food daily, and was always up long before breakfast and 
ready to converse with the first person whom he might 
meet, stating his plans for the day ; at one time he had 
schemes for lighting the city by some new system which 
he had devised, and on another occasion he made a contract 
for paving two or three of the principal streets of the city ; 
at another time he had an invention which he had recently 
perfected for making artificial teeth, and he desired to go to 
Washington for the purpose of securing a patent upon it at 
once, before some other enterprising dentist should get the 
start of him. When this was refused, he threatened and 
said the Retreat would be obliged to pay for his loss, as 
his detention here prevented him from becoming a very 
wealthy person. Afterward he was extremely anxious to 
work about the lawn, at times in trimming the trees and 
shrubbery, but he could not be trusted to do anything alone, 
as he would cut away nearly all the limbs of the trees, if 
permitted to do so. The attacks of alternate excitement 
and depression continued until his seventy-seventh year. 
During many years he had an enlarged prostate and latterly 
cystitis. He gradually failed during the last period of 
excitement, from the loss of sleep, pain, and irritation 
attendant upon the disease of the bladder. 

When excited there was nearly always so much of 
method in his plans, and he was able to explain them in so 
plausible a manner with some seemingly satisfactory reason, 
he was so confident that he was all right himself, and that 
there was no need of restraint or caution in reference to 
him and his plans and movements, that persons casually 
meeting him could not think him insane and needing 
restraint. As has been before remarked, even his wife 
thought "there was not much wrong with his mind." 



254 LECTURES ON MENTAL DISEASES. 

While never specially attentive to the female sex, yet he 
was extremely polite, and was always suspecting others of 
being more than polite to them. 

During the initiation of the final period of excitement, 
he left the grounds without permission and went to the 
United States Hotel, engaged a suite of rooms, returned 
to the Retreat, and told what he had done, and said that he 
intended to celebrate his seventy-seventh anniversary there, 
and also hereafter to make his residence at that hotel. 
When told that he must remain at the Retreat, he became 
very irritable and much excited, on one occasion struck the 
attendant, and on another threw a quantity of water over 
the steward while he was passing through the hall, and 
when expostulated with, struck him a violent blow on the 
head, and declared that all the officers and attendants of 
the institution were frauds and cheats, and he would burn 
the buildings down before he left them. Such violent con- 
duct, however, had never been exhibited on any other 
occasion of his excited periods. 

The melancholy, during his periods of depression, was 
never of a very profound character; it usually appeared 
quite suddenly after what was apparently a culmination of 
the excitement, or after it had arisen to such a degree as to 
require decided measures of restraint. All at once he 
would be found in the morning sitting quietly in his room, 
properly, and even carefully dressed, and sometimes read- 
ing his Bible. When questioned he generally replied in 
a subdued, quiet tone, and was always confident that he 
should never recover; he seemed humble and exceedingly 
mortified at what he had done when excited, and carefully 
hid away his shooting-jacket and top-boots. During these 
periods he attended the chapel exercises regularly, and 
gave the closest attention to what was said and done ; 



FOLIE CIRCULAIRE. 255 

his appetite became less, and he invariably complained of 
dyspepsia ; he never left the hall for a walk, or even his 
room, unless requested to do so. 

The whole round of excitement, depression, and compar- 
ative insanity, after he came to the Retreat, generally 
covered about one year. Whether the experiences of the 
many years prior to that time were limited to a like period, 
does not appear from the history. In this case the favorable 
stage generally continued nearly twice as long as the con- 
ditions of excitement and depression. The state of excite- 
ment for many years was during the summer months. 

In three or more of the cases of this form of disease 
which have been under my care, and one of which at the 
present time of writing is in the Retreat, the period of 
excitement has been in the winter season. 

Prognosis. — The prognosis in cases of folie circulaire 
is always, or nearly always, unfavorable. This, at first 
view, seems to be remarkable, especially as the group of 
symptoms consists of a combination, in rhythmic alterna- 
tion, of those present in two forms of insanity, mania and 
melancholia, in both of which, when uncomplicated, the 
prognosis is usually favorable. The explanation, however, 
maybe found in one of the elements of its aetiology already 
referred to, i.e., the powerful influence of a morbid habit 
which has become fully established in the delicate tissues 
of the brain. 

A similar habit, or a recurrent morbid action, affecting 
other sections of the brain tissues, is found in cases of 
epilepsy and chorea. Recoveries are exceedingly rare in 
both of these forms of disease when chronicity has once 
become established. We are unacquainted with any form 
or system of treatment which has thus far in the history 



256 LECTURES ON MENTAL DISEASES. 

of the treatment of the disease proved to be of any avail 
in arresting its continuance and progress. 

Patients not unfrequently live many years, retaining a 
considerable degree of their normal vigor, and do not 
usually pass into a condition of dementia. 



LECTURE XIII. 



DEMENTIA. 

Dementia and Idiocy — Distinction — Definition of Dementia — Importance of 
Averting an Issue of Dementia in Cases of Mania — It Rarely Occurs as a 
Sequel of Delusional Insanity — Symptoms — The Degree of Dementia 
Varies Very Much in Different Cases — Prevalence Among Chronic Cases — 
Periods of Excitement — The Transition to a State of Dementia is Generally 
Gradual — Third Class of Dements — Symptoms — Delusions — Sequential to 
Attacks of Mania and Melancholia — Three Forms of Dementia — Ten- 
dency to Merge into Each Other — Lines of Clinical Distinction Cannot 
be Definitely Drawn — Cases I and 2 — Prognosis in Primary Dementia — 
In Secondary Delusional Insanity — Treatment — Importance of State Pro- 
vision for Proper Care — Two Methods — Boarding Out of Such Patients 
Among Farmers — Public Institutions — Advantages of the Latter Method. 

From the time of Esquirol to the present a distinction 
between dementia and idiocy has been recognized by 
alienists. It is not easy in a few words to accurately define 
either of these mental states. They resemble each other 
in the presentation of similar and important features. In 
both there exists an enfeeblement of the mental faculties, 
and in extreme cases almost an extinguishment of the in- 
tellectual life. But in the idiot these faculties have never 
existed except in a nascent state; the brain centres upon 
whose activities they depend for exhibition have never be- 
come developed. Hereditary, conceptional, or pre-natal 
influences have crippled the structural growth before post- 
partum experiences began to exist. 

Not so with the dement. In his case the development 

257 



258 LECTURES ON MENTAL DISEASES. 

of faculties, mental and physical, may have been, so far as 
external indications gave evidence, as perfect as in ordinary 
children: the unfolding of both proceeds pari passu ; but 
after the experience of some form of mental disorder, or 
a long-protracted mental strain, generally during the 
adolescent period, there supervenes a cerebral affection 
which Esquirol has described, in a few words, as " ordi- 
narily without fever, and characterized by enfeeblement of 
sensibility, intelligence, and the will." Another form of 
expression would be — impairment, of the psychical, sen- 
sory, and motor centres of the brain. 

This definition, however, does not adequately differen- 
tiate dementia from idiocy — nor does it indicate the some- 
what extensive range of mental conditions which it is used 
to cover. In one way all insanity indicates an impairment, 
and consequently an enfeeblement, of the mind. Certainly 
all legal insanity presupposes this, and, in consequence of 
it, the legal procedure in restricting the liberty of the in- 
dividual, and assuming the care of his property, is instituted. 
But the term dementia is used in medicine in a more re- 
stricted sense, and is applied to mental states which gener- 
ally are sequential to other forms of insanity. Indeed, 
there exists no doubt that in the large majority of cases it 
is consecutive to mania, melancholia, and alcoholic insanity. 
This is the issue which is to be dreaded and if possible 
guarded against in the management of these forms of 
disease. Age and inheritance are influential factors in 
averting its advent. After thirty or thirty-five years of age, 
the brain has become so developed and its cellular structure 
so fully invigorated that it more readily endures the expe- 
rience of excitement without failure of its energizing capa- 
city. Discipline of the mental and physical organs in early 
life is of the highest importance as a preventive. 



DEMENTIA. 259 

In cases of primary delusional insanity and folie circu- 
late, dementia rarely occurs until after many years, and it 
is then much less pronounced in character. Instances are 
on record in which the latter form of disorder has existed 
with its alternate states of excitement and depression during 
twenty and even thirty years without the occurrence of 
pronounced indications of dementia. An instance of this 
kind is described on page 251. The brain which is handi- 
capped by inheritance, or enfeebled by excesses or unfav- 
orable hygienic influences, is the one that succumbs after 
the experience of an attack of insanity. 

Symptoms. — The acute and active manifestations of 
mania, the mental pain and self-accusatory conditions of 
melancholia, generally subside in the course of a few- 
weeks or months, and sometimes are succeeded by a 
condition of profound quiet. The patient remains for 
hours, if permitted to do so, by himself, with his eyes 
closed, or looking on the floor, with little movement of 
the person or with little expression of the face. The 
form which in health had been so active and full of 
bounding life, energy, and happiness, with all the possi- 
bilities of human intelligence and enjoyment before it, is 
now, after the storm of an acute attack of insanity has 
passed, an abject and pitiful sight ; sometimes too indiffer- 
ent to take even the requisite amount of food and drink, or 
to attend to the calls of nature ; in a condition which has 
been rightly termed the " tomb of human reason." All 
" the pride and splendor of the intellectual life " has faded 
away into a darkness so profound that it seems impossible 
that the light of reason should ever again penetrate and 
banish it. 

The intensity and character of this state, however, varies 
very largely in different individuals. With some it is com- 



260 LECTURES ON MENTAL DISEASES. 

paratively slight ; you will discover no delusions and ob- 
serve only that the mind has less than its normal activity 
and is partially indifferent. It requires more than usual to 
rouse and interest the person, to engage the attention ; but 
when he once becomes interested, the mind appears to 
operate slowly and in its usual channels of thought. Re- 
plies to questions and ordinary remarks will be free from 
anything abnormal, and the judgment correct concerning 
such daily experiences and occurrences as he passes 
through. 

Between these two conditions there are all shades and 
degrees of mental enfeeblement and peculiarities. In pass- 
ing through almost any of our older asylums, you will 
find more than half the number are the results of antece- 
dent attacks, and that they present evidence in dress, coun- 
tenance, gait, speech, and almost every act, that they are no 
longer like their former selves. They constitute " a hope- 
less majority." 

Young men who in former days had experiences of am- 
bition, and dreamed, as we all do at times, of that golden 
future when our long-cherished hopes and aspirations shall 
be more than realized, men whose abilities gave promise 
to their friends and companions of preferment in the walks 
of professional or political life, to-day walk only those 
dreary halls, from which ambition and pride have forever 
fled away. Those loves and hopes which are born and nur- 
tured of a healthy mind no longer haunt the recesses of the 
brain, but in place of them there float through it dim, 
shadowy, and grotesque forms of the conceptions and 
opinions which once held sway there, but which now con- 
stitute a kind of inner world by themselves. If, for a 
moment, some old emotion or ambition comes welling up 
through the channels of thought, trying, as it were, to force 



DEMENTIA. 26 1 

itself into reality, it seems to flicker away and die, like a 
miserable abortion. Or if the physician comes along, and 
with a friendly look, touch, or word tries persistently to 
rouse the inner self into activity, and to recall some long 
ago familiar name, or snatch of song, or face, the light, per- 
chance, may come again in the eyes ; some expression of 
remembrance may escape the lips ; some sentence implying 
the exercise of memory may be uttered, and then silence 
reigns within. 

Again, there come periods of over-activity, when thought 
after thought flashes through the brain, and the power of 
memory comes back with unwonted activity. The scenes 
of bygone years, the experiences of youthful days supposed 
to have been buried long since in the shadows of cortical 
oblivion, come back again fresh and clear as those of yes- 
terday. The mind recounts and revels in them, as in the 
freshness of youth-time. Such exhilaration of feeling 
comes over the brain that the patient will tell you he never 
was so well in his life, and all the assertions of all the 
doctors in the universe can never convince him of the 
contrary. 

It would be a mistake to conclude that patients pass at 
once from the excitement and exaltation in mania or the 
depression of melancholia into the state of dementia. On 
the contrary, the transition is a gradual one ; in some, ex- 
tending over a few weeks, and in others, months. The 
emotional states become less acute and pronounced,the senti- 
ments of dislike and hatred give way to a state of indiffer- 
ence, the excitement of motor activities becomes less and 
the pronunciation of words relatively slow. Irritations of 
the periphery reach the sensorial centres and produce a 
more feeble reaction. The memories of recent events do 
not spontaneously revive, nor can they be called into con- 



262 LECTURES ON MENTAL DISEASES. 

sciousness. The patient is unable to execute any of the 
fine muscular movements in doing work of any kind. He 
does not read or write or express a desire to see his friends. 
He becomes more and more silent and has few wants. He 
easily loses the thread of his thought, and fails when he 
makes an effort to respond to a question if it requires 
several words. Concepts which may rise into conscious- 
ness are not accompanied with others, or, if they are, do 
not combine to form purposes, or retain much of sequence 
or order. One by one the mental and physical faculties 
seem to shrivel and become almost useless, until the picture 
of dementia becomes complete, and the patient becomes 
only a wreck of his former self. 

There is, however, a third class in which the abnormal 
mental activities issue in a state to be differentiated from 
those already referred to. They neither sit in the dark- 
ness of dull silence and sluggish bodies, indifferent alike to 
sunshine and cloud, heat and cold, nor are they swayed 
by the occurrences of mental storms which sweep through 
the brain from time to time, always leaving it weaker, duller, 
and less responsive to external stimuli than before. They 
pass into a mental condition which partakes only in a slight 
degree of these states, and are never greatly excited nor 
much depressed. The emotional and physical elements ot 
mania and melancholia are absent, and yet the mind is 
buoyant and hopeful. General sensibility is diminished, 
but the organs of sight and hearing are generally free from 
hallucinations, and the automatic activity of the brain is 
often increased. Impressions from without reach the sen- 
sorial centres, but are imperfectly radiated to the cortical 
centres ; or, when radiated, result in incomplete ideation ; 
the co-ordination of certain nerve elements essential to this 
process is wanting, and hence the disjointed and ragged 



DEMENTIA. 263 

character of ideas and beliefs. Impressions made upon the 
periphery follow each other into the brain quickly, but are 
rarely formed into a normal totality. In short, the com- 
bined activities of the ideational centres, which are essential 
to the formation and synthesis of concepts and ideas into 
normal beliefs and judgments, have become deranged. The 
attention reaches only the most patent qualities of things, 
and is expended on what first reaches the sensorium, while 
that which constitutes the remaining and most important 
part is unheeded. Hence, impressions are transient and 
remain unrecorded ; the ability to recall former ones is 
impaired, as is also the capacity to form logical inferences 
and correct judgments, while imperative concepts rule the 
range of mental activities. 

Such changes in the psychical centres and their activi- 
ties doubtless constitute the basis of delusions, which pre- 
sent the most striking feature of this morbid mental state. 
But they are to be distinguished in the character of their 
genesis from those which arise in primary delusional 
insanity. They are always sequential and secondary to the 
states of mania or melancholia, while the latter are rarely or 
never so. They generally relate to one or to a few subjects, 
and hence the condition has been termed monomania. 
And if this name is to be used as descriptive of any class 
of cases, that which we are now studying is the proper one. 

The maniacal state, however, rarely or never appears in 
those cases which are typical ones of the class under con- 
sideration. They never become excited or indignant in view 
of the contrast as between what they believe themselves to 
be and the conditions which surround them. Their liberty, 
the first essential of kingly prerogative, is abridged, and 
they become servants and useful helpers about the halls 
and in the laundry and kitchen, and yet fail to perceive 



264 LECTURES ON MENTAL DISEASES. 

any incongruity with their pretensions in so doing. The 
element of weakness or dementia is, after all, the one most 
conspicuous in the character of mental activities. This is 
certainly the case after the states of mania and melancholia 
have fully passed away. While some of these still remain, 
and the secondary state has not yet become fully estab- 
lished, the patient may at times become more or less excited 
or angry, especially if his claims and pretensions are not 
recognized and acceded to or his assertions are contra- 
dicted. He may, during the stage of transition, be able to 
appreciate the impropriety of his doing any menial service, 
and protest in an emphatic manner if urged to work. But 
in proportion as the mental activities which have been 
conspicuous in the person's emotional states" subside, and 
the field becomes more and more limited, does the definite- 
ness of some delusion or delusions become pronounced, 
and the element of dementia in all the higher ideational 
centres become apparent. 

Here, then, are three more or less distinct classes of cases 
which have taken rank under the term dementia : — 

1st. Those who in the outset do not experience any 
distinct or protracted period of mania and excitement, but 
soon become less and less responsive to external stimuli ; 
exhibit a constantly diminishing interest in the past or 
their present surroundings ; become apathetic, careless, and 
negligent of person and proprieties, with little or no spon- 
taneity of mental activities, and move forward in the down- 
ward course to a permanent state of dementia. 2d. Those 
who are, the larger part of the time, in a state of partial 
dementia, but experience periods of maniacal excitement, 
generally attended with transient delusions or hallucina- 
tions ; and 3d. Those whose mental activities are domi- 
nated chiefly by imperative concepts and one or more 



DEMENTIA. . 265 

systematized delusions, which mainly cover the field of 
consciousness. 

The mental state covering the first class has been termed 
primary dementia. That of the second, secondary 
dementia, and that of the third, secondary delusional 
insanity. The first is the most typical form of dementia. 
The others are secondary, always sequential, and exhibit 
more or less of other phases of mental disorder. In the 
first, the whole physical system sympathizes with and cor- 
responds in the discharge of its functions with the mental 
state ; while in the other two forms this correspondence is 
partial and sometimes very slight — especially in the third. 
The aetiology of the first consists more largely in heredity, 
pre-natal impressions, infantile diseases or accidental ex- 
periences of early childhood ; while that of the others is 
more intimately connected with the antecedent morbid 
experiences of the brain in attacks of mania which have 
been attended with excessive or protracted emotional 
excitement. In the first the capacity of the brain for 
psychical functions appears to have become reduced to, 
and remains permanently at, its lowest ebb; while the 
ebb and flow continues in the others at irregular intervals. 
The brain energy of the one has irrevocably oozed away 
during the brief day of its earthly life, while that of the 
others is only shattered and deranged in its manifestations. 

It is not, however, my purpose to intimate that there 
exist sharply defined boundary lines between these forms 
of mental disorder. On the contrary, while in the more 
typical cases of each there do exist clinical distinctions, 
always to be recognized, yet they all tend almost insensi- 
bly to pass into each other, the essential common element 
being dementia. That is, they all alike arise directly 
from a diminished capacity of the brain cortex in securing 
23 



266 LECTURES ON MENTAL DISEASES. 

for itself, from nutriment and sleep, the energy essential to 
its normal functional activity. 

Case I of primary dementia : H. H. is the son of a 
highly intellectual father and a mother who has been insane 
for many years. The grandfather on mother's side died 
of " some form of brain disease." The patient had been 
kept very closely at study (this having been regarded as 
the best method of insuring the brain against the develop- 
ment of any inherited tendency which might exist) from 
early childhood, under private tutors, and urged to the full 
extent of his ability and endurance. At seventeen years ol 
age he was examined for admission to college, and is said 
to have passed with a very high stand. Within a few 
weeks afterward he rather suddenly lost his mental vigor, 
could not play games successfully with his younger brother, 
who had been his constant companion. His former interest 
in, and love for, books disappeared, and, indeed, all ability 
to be interested in anything. He was taken to the country 
and spent several weeks of out-door life. Every effort was 
made to interest him in sports, shooting and hunting, but 
with little or no effect ; listlessness and indifference con- 
tinued to increase, and he was returned to his home. 

At the time of first examination the mind was in a state 
of apathy and dullness. Questions addressed to him ap- 
peared to reach the sensorium very slowly, and often it 
was necessary to repeat very simple questions two or three 
times before their meaning was apprehended. Such replies 
as he could form into words and sentences also came very 
slowly and with a drawling pronunciation. He would re- 
main by the hour in his chair and rarely initiated motor 
activities or reading. 

Three months later, the mental action had become much 
weaker. He rarely made an effort to reply to questions ; 



DEMENTIA. 267 

had a stupid and dull staring expression in his face and 
eyes, but when told to rise and walk would do so. When 
asked to read, would look apparently at the page, but did 
not appear to comprehend a sentence of what was printed 
on it. The circulation had become feeble and the hands 
cold, moist, and clammy. He required baths frequently 
and friction of the extremities. He walked with an attend- 
ant about the lawn, but moved feebly and slowly, with 
head bowed forward like an old man. 

One year after admission he had become a typical picture 
of a primary dement. He would remain wherever he was 
located, on chair or lounge, almost without movement of 
body or extremities, during hours if permitted to do so, with 
head bowed forward and chin almost on his breast ; saliva 
dribbled from his mouth, his urine and feces were passed 
at any time or place, with no intimation on his part of 
desire, and with no appreciation of what had occurred. He 
never expressed a desire for anything whatever, by word, 
look, or motion. He never indicated the sensation of 
thirst or hunger, nor made an effort to take food or 
drink. When food or drink was placed in his mouth 
he partially masticated and swallowed it. He seemed to 
vegetate physically, and thus lived on from year to year. 
He is six feet in height when standing straight, but with- 
out a beard, and his face now looks as young as it did ten 
years ago. 

The next case is of interest in two or more respects. It 
illustrates the occurrence of an intercurrent disease, or 
rather of two diseases existing at the same time. It 
also presents an example of that feature of dementia 
which is observed in some instances, viz., a tendency to 
develop rapidly, particularly in loss of intelligence after 
some unusual experience, especially if it is of such a nature 



268 LECTURES ON MENTAL DISEASES. 

as to call for any considerable expenditure of nerve energy. 
This is observed to occur in some instances after a short 
period of excitement or of insomnia. 

F. M., aged twenty-two, well formed, five feet ten inches 
in height, dark complexion, dark eyes and hair, has a dull 
expression of countenance but replies readily to all ques- 
tions addressed to him. He is said to have no inheritance 
of insanity and was unusually bright as a boy. He was 
circumcised when ten or eleven years of age, as he had a 
habit of wetting his bed at night and it was thought this 
might prove an effectual remedy. He was admitted to the 
university at the age of sixteen and remained there a year. 
About this time he exhibited some indications of not being 
well ; became irritable and displayed temper upon slight 
provocation. His father removed him from the university 
and went with him to Europe, where he remained and 
traveled several months. After he returned he was some- 
what improved in general health but still gave no indica- 
tions of interest in study. Nor did he express a desire to 
enter upon any occupation, and before long again became 
irritable, restless, and complained that his father had ruined 
him for life because he had permitted a surgeon to circum- 
cise him. This seemed to worry him and he frequently 
alluded to it. He would not read, and exhibited no interest 
in what had formerly interested him greatly. About this 
time there appeared an eruption, which covered his face and 
some parts of his body, of the character of acne. He was 
then sent to a water-cure establishment, but without benefit, 
and with more decided indications of mental impairment. 

At the time of admission the upper part of the face and 
forehead were covered very thickly with the acneal erup- 
tion. It also covered a space between the shoulders, and, 
to some extent, the breast. There were two zosters (her- 



DEMENTIA. 269 

petic) one on the anterior left side and the other on the 
posterior left. There were also scars on both sides of the 
body, where zosters had formerly existed and were now 
healed. He was well nourished, but had cold and moist 
hands and feet. He was ready to walk with an attendant 
and was equal to a large measure of daily exercise. He 
slept well and was inclined to lie during the day, when in 
the hall, on the lounges, but rarely read or initiated any 
conversation. 

During the first few months after admission he seemed 
to improve a little, and his father became very hopeful, 
though an unfavorable prognosis had been given. He 
visited him often and took him into the city and country. 
Finally, on one of these excursions, the son suddenly 
started and ran from his father with* great speed, and 
succeeded in escaping from the city, and remained one 
night in some woods not very far distant, where he said he 
slept on the snow. Fortunately, it was not very cold, and 
he was protected with a heavy coat. In the afternoon of 
the next day he returned, and told where he had been. 

Directly after this experience he began to give indica- 
tions of greater mental feebleness, became apathetic and 
dull, and continued rapidly to degenerate, until at the time 
of this writing he is careless as to dress, and soils himself 
nearly every night and occasionally during the day. He 
is fast passing into the condition of the case already 
delineated. 

The prognosis in primary dementia is always unfavor- 
able. The mental life of the cortex appears to have run 
its course and dies from exhaustion, while the organic life 
of the system still retains some measure of activity and 
endurance. Its subjects comprise the cases which have 
passed beyond the portal and are on the farther side of 



2/0 LECTURES ON MENTAL DISEASES 

hope. They are the ones for whom the selectmen and 
taxpayers of towns and cities never cease, day nor night, 
to offer prayers, that they may become translated, and 
clothed upon with glorified bodies. 

While the prognosis in secondary delusional insanity 
and dementia is also unfavorable, yet the prospect is not 
so profoundly dark and hopeless. Some occasionally 
recover, and many improve. They retain some degree ol 
mental capacity, which varies greatly in different cases, and 
a considerable per cent, may, in time, become capable again 
of accomplishing some kind of simple work, and also of a 
greater or less degree of enjoyment. 

Treatment. — In view of the unfavorable prognosis of 
dementia it may be regarded as unnecessary to occupy 
attention in considering the subject of treatment. This, 
however, would be a mistake. Dementia comprises those 
classes of the insane which constitue one of the great prob- 
lems of psychiatry at the present time. The manner in 
which they shall be cared for, the methods to be adopted 
for their supervision and humane management, certainly 
forms one of the most serious questions with which modern 
society has to deal. One point has been pretty definitely 
settled in regard to them, and that is that they shall be 
regarded as wards of the State unless they have sufficient 
property for their comfortable support. Not many years 
ago it was considered as feasible to care for them all in large 
asylums which would serve alike for the acute and chronic 
insane. But as the number increases and the hopelessness 
of recoveries from among the ever-increasing numbers 
of them becomes more apparent, the question of economy 
thrusts itself into the field, and the inquiry is made whether 
they may not be properly and humanely cared for in some 
less expensive manner, and also be made to contribute 



DEMENTIA. 2J I 

toward their own support. In former times they were left 
to roam from place to place, and subsisted on" such scanty 
supplies as they could gather from those who were dis- 
posed to feed the hungry. The conditions of civilization 
have now changed and society is beginning to realize in 
some measure its duty to interest itself in, and care for, 
these helpless ones who can no longer care for themselves. 

Two methods of accomplishing this have been advocated, 
and to some extent adopted. The first consists in providing 
homes for them, or for some classes of them, among the 
rural population of the State, where they may become 
members of the families in w r hich they live, and also, to 
some extent, be employed in such work as they are capable 
of doing. They are to be under the general supervision 
of a Board of Lunacy Commissioners, who shall visit them 
from time to time, and may also be under the professional 
care of some country physician. It is thought that such a 
disposition of them would be preferable to life in a public 
institution, which necessitates a considerable restriction of 
personal liberty. The objections to this plan consist 
mainly in the impossibility of any efficient system of super- 
vision, and the consequent liability to abuse and ill-treat 
ment. 

The other plan is to place them in public institutions 
especially adapted to the care and use of such patients, 
and where they would be under the special observation of a 
physician and attendants educated for the purpose. 

The liability of abuse or unkind treatment would be 
reduced to a minimum by this method. They could be 
employed in some kind of labor, according to the judgment 
of the physician. They can always be sure of an abundance 
of properly prepared food, occasional means of amuse- 
ment, and some degree of education in some form. This 



272 LECTURES ON MENTAL DISEASES. 

plan also secures the possibility of ministering to dis- 
ordered minds in all known methods, for the purpose of 
restoration or improvement ; and if recoveries are ever to 
occur among this class, they must come mainly through 
agencies devised for re-educating the brain in the line of 
former duties and activities. 



LECTURE XIV. 



ADOLESCENT INSANITY. 

Two Epochs of Life — Adolescence and Senility — yEtiology — Heredity — Char- 
acteristics of Pubescence and Adolescence — Motor Activity — Evolution 
of Sexual Functions — Development of Brain Capacity — Reasons Why 
there Occur so Few Cases of Insanity at these Periods of Life — Causes 
Ordinarily Potent Not Operative — Physiological Reasons — Heredity 
Comes into Forceful Activity Later in Life in Most Forms of Disease — 
Symptoms — Exaltation or Depression, Both in a Modified Form — Little 
of Maniacal Excitement or of Mental Pain — Both of Short Duration, 
and Succeeded by a State of Hebetude or Apathy — Case Illustrating Ten- 
dency to Recurrence. 

Adolescent insanity is that form of mental disorder 
which is connected more especially with the period of 
development, and is in this respect the antithesis of that 
connected with old age. The one occurs in connection 
with the evolution of both physical and mental capacities ; 
the other with the period of involution. 

Mental processes are more or less affected by even the 
daily modifications which occur in the brain, and more 
especially are they influenced by the more profound ones 
which occur at the two great epochs of life. These epochs, 
therefore, become more or less critical in the history of 
every individual. In old age the process of organization 
no longer keeps pace with that of involution, in conse- 
quence of a diminution of the vital energy of the system ; 
but in the period of youth the ratio of progress in these 
24 273 



274 LECTURES ON MENTAL DISEASES. 

processes is reversed — evolution and organization more 
than keep pace with that of involution, and the system 
increases both physically and mentally. In all cases of 
normally organized and healthy persons these processes 
proceed in harmony the one with the other, and the system 
is developed in accordance with the law of its being ; but 
if from any cause or causes the consonance of this mutual 
growth is disturbed, there result manifestations of derange- 
ment in all degrees, sometimes in the mental, and at others 
in the physical system, and not infrequently in both. 
Illustrations of the grosser forms of all these are observed 
in cases of scrofulous or tubercular disease occurring in 
childhood and youth, and in the different degrees of im- 
becility and idiocy. And when we consider the number 
of factors which enter into and influence this development 
of the system, how delicate is the adjustment and play of 
these upon one another, and upon the whole force of the 
system itself, it is by no means remarkable that these 
dependencies sometimes become deranged, thus producing 
disorder. Indeed, it is remarkable that they no oftener 
become so, especially during the pubescent period, when 
all the elements of the structure are in so unstable and 
changeful conditions ; and were it not for the force of 
healthful inheritance and surrounding influences it would 
be far otherwise. 

-/Etiology. — On this point it may be stated that hered- 
ity is a more important factor and apparently exercises a 
more direct influence in the production of this form of insan- 
ity, than any other. Indeed, so generally is it developed in 
connection with or from this influence, that Dr. Clouston 
writes that he has never known a case in his large experi- 
ence, in the history of which there could not be traced a 
hereditary taint or neurosis. The degree in which this 



ADOLESCENT INSANITY. 275 

inheritance will affect the system and lead to derangement 
of healthy activities will depend not only on the conditions 
of life, that is, whether favorable or unfavorable, but also 
upon the counteracting healthy heredity from ancestors, 
and more especially from one healthy parent. This latter 
is, in the majority of cases, quite sufficient to offset the in- 
herited possibilities of disease, so that individuals pass safely 
through the period of development ; and most certainly 
will this be likely to prove true if such persons are sur- 
rounded by favorable conditions, and have the advantage 
to be derived from a definite and systematic course of 
physical and moral education. Hence we shall find that a 
majority of the cases of pubescent insanity arise in persons 
who inherit neurotic tendencies, and who are either over- 
worked or underworked. Many of them are left too much 
to themselves, and have little or nothing to do in the way 
of labor and regularly imposed tasks ; and are not required 
by the force of family discipline to learn obedience to the 
laws of home life, health, and activity. In such persons 
the inhibitory centres of the brain are the most sensitive 
and inefficient in the economy of activities, and require 
invigoration by all those external appliances which experi- 
ence has proved to be of service. 

In order, however, that it may be more apparent why 
the periods of pubescence and adolescence are those more 
likely to be invaded by some of the various forms of nerv- 
ous disorder in those who inherit any of the neuroses, it 
may be desirable to refer to some of the more obvious 
characteristics which distinguish these periods of life. 

Motor Activity. — One of these characteristics is the 
evolution of such forces of the nervous system as con- 
stantly seek expression in outward activities. All 
know from experience how difficult it is for young persons 



276 LECTURES ON MENTAL DISEASES. 

to restrain this tendency, and that one of the keenest 
of delights is experienced in the motions of the various 
organs of the body as well as the brain. Games of almost 
all kinds, which require a considerable expenditure of 
nervous energy, are eagerly followed. Exhilaration, a 
large flow of good feeling, and a fuller measure of delight 
in existence, come to persons at this period of life who are 
able to regularly and judiciously, and many times even 
injudiciously, indulge such activities. Indeed, that young 
person who does not so seek to expend a considerable por- 
tion of the nervous energy of his system, is likely to be 
regarded as in an abnormal condition. 

But this is not all, nor the most important consideration, 
nor even the meaning of the highest purpose of this 
tendency. This, doubtless, lies in the fact that these 
activities, and the consequent changes which result in the 
various tissues of the system, have a powerful influence in 
causing a more firm and stable condition in them. If it be 
a law, as is claimed by Mr. Herbert Spencer, that there 
exists a pretty constant relation between the size of 
the nervous system and its tendency to, or power of, 
motion, either in its simple or complex combinations, 
then it becomes apparent why motion seems to be so much 
more a necessity to childhood and adolescence than to later 
periods of life. The brain at this age sustains a larger pro- 
portion to the remainder of the system than ever afterward, 
and one of the most important problems of physiological 
education is how to secure the expenditure of this surplus 
force developed by it in such activities as will serve to 
make the system vigorous and healthy. 

Another feature especially characterizing this period is 
the evolution of the sexual functions. It goes without 
saying that this physiological function exercises the most 



ADOLESCENT INSANITY. 277 

powerful influence over the whole being from the time of 
its appearance forward, during thirty-five or forty years. 
Its manifestations mark a new era in life, and greatly 
change or modify those tendencies which have hitherto 
existed. Its normal development is generally attended 
with enlarged views and expectations ; the individual vision 
is no longer limited to self and selfish amusements, but now 
extends to another world — that of sensation and love. 
Hitherto the society of the opposite sex has been either 
shunned or regarded with indifference, but now it becomes 
a delight and a requisite to happiness. The significance of 
family life becomes more apparent. Mere existence and its 
present enjoyment no longer bound the horizon of the mind, 
but it begins to look forward to the future, and question 
what is to be sought in it. Forethought and preparation 
for the duties and responsibilities of life largely super- 
sede the passion for play which has hitherto exercised so 
strong an influence. Girls no longer care for dolls, which 
are now consigned to the limbo of forgotten things. With 
the enlargement of the system and the establishment of 
the catamenia, there exists a specially sensitive condition 
of the nervous system, which is often manifested by 
vague emotions and longing for indefinite and imperfectly 
understood wants ; and not unfrequently physical likings 
and tastes change ; persons and things become distasteful 
which formerly had been regarded with favor. The emo- 
tional centres are more active, and the whole nervous 
system more sensitive, which not infrequently leads to 
chorea, hysteria, or epilepsy. In fact, the evolution of the 
sexual functions profoundly affects the whole system, and 
taxes its energies more strongly, perhaps, than any other. 

One more important change at this period requires 
especial attention, and that is the development of brain 



278 LECTURES ON MENTAL DISEASES. 

capacity. The brain at the time of birth may be roughly 
estimated as having attained one-third of its full growth. 
It attains a second third at or before the age of fourteen 
years, and the last third about twenty-three (in some cases 
it may continue to increase some years longer). This last 
third of increase relates more than either of the others to 
the development of the central ganglia, the blood-vessels, 
the caudate cells, and the grey substance of the cortex. 
The optic thalami and the corpora striata, which are sup- 
posed to be centres for reinforcing and radiating nervous 
irritations or sensations to the nerve cells, and the efferent 
nerves, become larger and more efficient in arranging and 
coordinating these impressions. The higher centres toward 
which these radiations are transmitted also become more 
fully differentiated, and the caudate cells, which in child- 
hood are not grown, now become fully developed, and their 
nervous filaments both enlarged and lengthened. In addi- 
tion to this, or in consequence of it, larger measures of 
nerve influence are communicated through the vaso-motor 
portion of the system to blood-vessels, which increase in 
size. By this means more blood is provided for all the 
above-named portions of the brain, and its capacity of 
activities is correspondingly increased. 

Passing now to the changes and development in the 
functions of the brain represented in mind, we find that 
they have proceeded pari passu with those of the brain 
itself. Processes of thought become stronger, impressions 
less evanescent ; experiences become organized into mem- 
ories, and memories into ideas, opinions, and purposes, so 
that the individual lives in the past, as well as the future. 
The several so-called faculties of mind, such as reason, 
judgment, and imagination, become more pronounced as 
the individual passes on through this period, so that it 



ADOLESCENT INSANITY. 2jg 

becomes, par excellence, the harvest time for attainment. 
In short, it is the period during which the motor centres 
are .enlarged and strengthened ; the function of propa- 
gating the species is established, and the higher brain 
capacities which will characterize the future individual 
are all evolved, and begin to come toward maturity ; and 
it is the evolution of all these which calls into activity the 
vital energy of the system to its fullest extent, thus ren- 
dering it most important to all, and critical in the lives of 
many. 

If, then, pubescence and adolescence are periods which 
are so important, and in many cases critical, and because 
of their peculiarities there exists a larger danger than at 
other periods of life, the question at once arises why 
there are so few cases of insanity compared with other 
periods of life. Not much more than five per cent, of the 
admissions to the Retreat during the last ten years have 
been under twenty years of age, and possibly not all of these 
could be regarded as cases arising from either pubescence or 
adolescence. The statistics of many other institutions would 
present a much smaller per cent, of admission under twenty 
years of age. The answer to the question, however, I 
think is not far to seek. 

In the first place, but few of the causes which ordi- 
narily are potent in the production of insanity during 
other periods of life are operative in this. The larger 
cares and responsibilities which are incident to the conduct 
of business and in providing for other persons have not 
yet been assumed ; there have never been protracted 
experiences of uncertainty as to the issue of important 
trusts and the care of property ; the numberless effects of 
poverty have never been fully realized, nor have those 
which result from the protracted use of stimulants or 



28o LECTURES ON MENTAL DISEASES. 

narcotics been experienced ; the sympathetic portion of 
the nervous system, which exercises such a profound 
influence on the mind in later life, has not become suffi- 
ciently developed to be greatly affected by disappointment 
and the loss of friends ; and such effects as do result 
soon pass away ; and, finally, the nerves and nerve cells of 
the brain have not become fully developed, and, unless in 
exceptional cases, have not become enervated by any pro- 
tracted and severe strain. In fact, heredity is about the 
only factor in the causation of insanity which can exert 
much influence at this period of life, aside from the devel- 
opmental processes above mentioned, and this influence, 
proceeding from the healthy parent, probably more often 
acts as a sufficient preventive than otherwise. 

In the second place, there exist physiological reasons 
why so few persons are affected with this form of insanity. 
It is a law that, in the development of the system, the 
highest qualities of the mind, such as reason, imagination, 
and judgment, are the last to become fully organized in the 
system, and these are consequently the first to suffer impair- 
ment in insanity. The period at which these brain charac- 
ters become fully established varies very considerably in 
different individuals, but as a rule persons attain to from 
sixteen to twenty years of age before any considerable 
progress is made in this physiological development ; and it 
is quite certain that those portions of the brain upon which 
these qualities of the mind depend continue to develop 
long after the latter age. While, therefore, they are in the 
process of development and are drawing to themselves the 
materials of the blood which are specially requisite for this 
purpose, and, furthermore, are free from those depressing 
influences which later in life affect them unfavorably, the 
integrity of their activities would not be likely to become 



ADOLESCENT INSANITY. 28 I 

affected, except in so far as they may become so from inher- 
ited qualities. And even this influence would be less oper- 
ative, while the brain yet remains in a partially developed 
condition, and its nerve cells and molecules are receiving 
supplies of nutritive material not only for their functional 
activities, but also for increase in growth, than it would be 
at later periods, when these physiological conditions are 
largely modified, and its cellular activities consist almost 
entirely in functional action only. 

This is true not only in reference to the effect of the 
heredity of insanity, but also of that of rheumatism, 
tubercle, and cancer. The peculiar diathesis does not 
manifest itself in full force and activity, unless in excep- 
tional cases, until some time after the system has become 
fully developed and exposed to such exciting causes as 
arise only during a mature age. 

But in certain cases in which the inherited tendency to 
insanity is strong, or which have been most unfortunately 
circumstanced in reference to conditions which predispose 
to a healthy development, it manifests itself generally in a 
manner peculiar to the period of life. This peculiar manner 
I have already referred to, as consisting not so much in 
either very active excitement or depression, or in system- 
atized delusions or protracted hallucinations of any of the 
special senses, as a derangement in the development of 
brain faculties. In other words, the evolution of motor 
activities and the sexual and intellectual capacities do not 
proceed with equal rapidity, but one or the other of the 
first two becomes exaggerated and over-active as compared 
with the latter. 

The grand evolution of all the functions and capacities 
of the system, intellectual, moral, motor, and sexual, cer- 



282 LECTURES ON MENTAL DISEASES. 

tainly causes one of the most critical periods which the 
system can pass through. 

The inhibitory centres are those which usually, in 
consequence of inherited or acquired influence, do not 
keep pace in this stage of development. I think this 
view of the subject will be demonstrated by the charac- 
ter of those cases the symptoms of which are soon to be 
detailed. 

Symptoms. — States of exaltation or depression may be 
present. The history of many of the cases which have 
come under my observation has indicated a period of more 
or less depression and morbid self-consciousness, with a 
tendency to brooding and silence, prior to the exhibition of 
marked excitement. Both states of exaltation and depres- 
sion, however, during the adolescent period, have a charac- 
ter peculiar to themselves, and while they resemble the 
same mental conditions when occurring in the adult system, 
yet they are not identical. They generally fail to attain 
to the fully developed characteristics and intensity of the 
latter. While the degree of excitement may be consider- 
able in some cases, yet it is of comparatively short duration 
The patient talks or shouts in an excited manner, is nearly 
always very egotistical, with a tendency to exaggerated 
motor activity, but he is much more easily diverted and 
quieted than the adult. While he may appear to be de- 
pressed, sad, and shed tears, yet there is very little of real 
mental pain, such as exists in the melancholia of a more 
mature age. In many of the cases the explosion of excite- 
ment is sudden and the display of motor activity great, 
but these states tend soon to become changed, especially 
in the younger patients, and they become less boastful and 
confident, and frequently settle down into a state of partial 



ADOLESCENT INSANITY. 283 

mental and physical hebetude, with a tendency to say little 
and sleep much. 

There can exist little doubt that this difference depends 
upon the undeveloped condition of the higher brain centres 
and nerve cells, to which allusion has already been made. 
As these become more numerous, and new and larger 
areas of brain tissue become engaged in mental and motor 
activities, the mind becomes enlarged, individualized, and 
strengthened ; and, consequently, when these elements 
become deranged, the product of disordered functions 
becomes correspondingly increased and intensified. The 
younger the patient, the less complicated are the mental 
disorders. 

There are, in fact, very few cases of insanity in persons 
under sixteen or seventeen years of age, in either sex, as 
compared with the number occurring between the age of 
eighteen and twenty-three or twenty-four. This is the 
case, notwithstanding the fact that the reproductive period 
has become partially established prior to this age. The 
evolution of this function is certainly calculated to test very 
greatly the functional activity of the brain and the whole 
nervous system, and we must account for the fact that it is 
attended so rarely with insanity by bearing in mind that 
the higher brain centres, nerve cells, and tissues have not 
yet become so highly organized and sensitive as to become 
easily deranged. 

The following cases will illustrate how comparatively 
short is the period of excitement, and also the tendency to 
mental lethargy and dullness which succeeds its subsidence 
when occurring before seventeen years : — 

Case i. — E; T., age seventeen, of light complexion, blue 
eyes, short in stature, and very boyish in his appearance ', 
was admitted in 1881. It was reported that he had attended 



284 LECTURES ON MENTAL DISEASES. 

school regularly, but did not learn easily, or have much 
interest in his studies ; still, he had been in general well 
behaved and obedient in conduct. A few months prior to 
his admission, he had become more than usually silent, 
was inclined to remain by himself, to shun the company of 
his brothers and sisters, and had lost all interest in his 
books, home-life, and society. He then began to take long 
walks by himself; seemed in better spirits ; spoke of going 
into some business for himself, and was so unusual in his 
manner of conduct, as to excite the anxiety of his parents. 
He then left home'suddenly, taking the train to M — , a city 
some two hundred miles distant. He was followed, and 
when found was in a confused and mildly excited state of 
mind, and unable to say where he had been or whom he 
had been with. 

After his admission he continued in this same general 
condition several weeks, never much excited or depressed 
long at any one time, and apparently able to reply to ques- 
tions only in monosyllables when depressed. He slept 
well at night, and almost every day passed several hours in 
a sleepy, semi-stupid condition, lying on a lounge in the 
hall. He could not be sufficiently roused to express 
interest in anything ; he never read books or newspapers, 
nor could he be induced to write at all to his father, who 
often wrote to him, and expressed the deepest interest in 
his welfare. He was treated with an abundance of exer- 
cise in the open air, indeed, was forced, much against his 
will, to take it, also with strychnia and phosphorus. After 
three months the mind began to show indications of more 
activity, and he made a most happy recovery without a 
relapse, returning home at the expiration of five months. 
He, however, remained at home only a little more than a 
year, when he was returned to the Retreat a second time, 



ADOLESCENT INSANITY. 285 

having become excited, and left home as before. He again 
passed through a similar experience in the form of disease 
and treatment, though he remained about seven months the 
second time before going home. He was at home only 
about one year, when he again passed into his former con- 
dition, and he was brought back a third time. At the time 
of this writing he has been in the Retreat nearly fifteen 
months, never acutely excited long at a time, but frequently 
passing three and four hours of the day in a stupid condi- 
tion on the lounge, and always sleeping enough at night. 
He is now making his third recovery, and will soon be 
ready to try the experiences of home-life again. During 
his third period of treatment, the state of hebetude has 
been more profound at times, and we have had much 
difficulty in preventing the habit of masturbation. To 
prevent this he has been kept in a condition of vesication 
for weeks at a time. It will be observed that each suc- 
ceeding stay has been longer, the characteristics of the 
disease more marked, and a recovery seems less probable. 
There have also been more indications of dementia during 
his last attack than in either of the others, though the 
mental symptoms, so far as they relate to degrees of 
excitement and dullness, have been quite similar. Since 
convalescence has become established this third time his 
brain has been more free in its activities than after his 
former recoveries. He seems more cheerful, rides and 
walks with pleasure, joins in the dances, writes short, 
connected, and intelligent letters to his father, and appears 
to be interested in reading during some portion of every 
day. 

The above case illustrates another peculiarity of this 
form of insanity, which is its tendency to recurrence. In 
the large majority of cases more than one attack occurs. 



LKCTURK XV. 



ADOLESCENT INSANITY. (Concluded.) 

Case 2 — As Age Advances the Tendency to a More Protracted Period of 
Excitement Increases — The Catamenia — Cases 3 and 4 — Absence of 
Acute, Prolonged Excitement or Great Depression, also of Fixed De- 
lusions and Hallucinations — Condition one of Partial Dementia — Cases 
Occurring at a More Advanced Age — Symptoms More Pronounced — 
In Females Absence or Irregularity of the Catamenia — Probability of 
Relapses — Importance of Avoiding a Too Early Removal from Asylum 
Life — Danger of Masturbation — Treatment — Importance of Restraints 
and Regularity of Life — Medication — Educational Influences — Occupa- 
tion. 

Case 2. — R. R. (female), aged sixteen, but appears 
younger ; a person of good habits ; had scarlet fever several 
years ago and diphtheria four years since. About a year 
prior to admission she had been sent to school in a convent; 
was very ambitious, over studious, and much chagrined 
because she could not dress as finely as some of the other 
girls in the school. Before leaving home had been much 
indulged by her father, her mother having died when she 
was an infant. She had also received unusual attention 
from others, and became vain of her personal appearance. 
For some reason, probably inability to go on with her 
class, she left school and returned home after a short trial 
in study. 

The development of insanity came on quite suddenly, 
after taking a long ride in the winter, soon after leaving 

286 



ADOLESCENT INSANITY. 287 

school. She became incoherent, hysterical, wildly talkative. 
This state passed away after a few days, and she became 
dull and inclined to wander about in an- aimless manner, 
and endeavored to leave home, saying she wanted to get a 
situation in some family, thought there was not much the 
matter with her, and became so persistent and determined 
to leave home, threatening to commit suicide if she was not 
permitted to do so, that it became necessary to restrain her 
by mechanical means. 

When admitted she was anaemic ; had a dry skin, a pale 
and slightly coated tongue, and feeble pulse. The memory 
and mental action were much impaired, the thoughts con- 
fused, and replies irrelevant. She had not menstruated for 
several months. She remained during several weeks in a 
listless and confused state of mind, with very little interest 
in what was going on around her ; was inclined to lie on 
the lounge in the hall during the larger part of the day, in 
a condition of semi-stupor ; when aroused would reply in a 
vague, abstracted manner, and talked sometimes incoher- 
ently about medicine, the convent, and staying all night. 
At other times would pay little attention to what was said 
to her; kept her eyes closed, was dull of apprehension and 
apathetic, requiring to be led to the dining-room to take 
food, and even to have it placed in her mouth, and then 
often left it unmasticated. During one period she required 
to be dressed and undressed like any child. At the present 
time she has recovered a considerable degree of her mental 
activity ; has become interested in reading, converses with 
the physicians and others ; has written a letter to her father, 
requesting to be taken home. She takes food more freely, 
and is willing to take more physical exercise. 

The immediate cause of the disorder in this case was, 
doubtless, over-study, anxiety, and chagrin that she was 



288 LECTURES ON MENTAL DISEASES. 

not able to achieve as high a stand in her class and appear 
as well as her schoolmates. These experiences, acting 
upon a neurotic temperament at that period of life when 
the normal forces of the system were being largely called 
into requisition to fully establish the reproductive function, 
proved sufficient to cause derangement of the mental func- 
tion. 

In my experience this tendency to stupor has been 
present in cases occurring before sixteen or seventeen 
years of age, and in females before the catamenia had 
become fully established. The regular appearance of this 
function is one of the most auspicious indications of an 
approaching recovery. In case it is long deferred the 
stupor may become very profound, the circulation of the 
extremities cold, the breath very offensive, all the secre- 
tions very deficient, and for the time being patients have 
the symptoms of primary dementia. 

In the cases already detailed, there existed enough 
excitement of the motor centres to lead to wandering (or 
an effort to do so) from home. While this condition con- 
tinued there was little mental excitement, but a confused 
state of mind, attended with inability to comprehend or 
appreciate the true relation of the environment. 

Case 3. — J. K., age sixteen, and small for his age, 
weighing only ninety-two pounds, and with a scar on his 
forehead from the kick of a horse, was admitted in July, 
1 88- His father and mother are separated ; his father has 
a violent temper and bad disposition. A few months 
previous to admission, he had become absent-minded ; lost 
interest in all employment; showed a disposition to be 
ugly ; on several occasions struck his mother and threat- 
ened to kill her. He could, however, conceal his vicious 
propensities when in the presence of strangers or persons 



ADOLESCENT INSANITY. 289 

not living with him. When admitted he was depressed, 
and at times inclined to shed tears. He confessed that he 
had masturbated, and said he had a " bad disease." He 
did not sleep well, and was often out of bed in the night ; 
refused his medicine, saying it was poison. He had an 
elongated prepuce, which was circumcised after consider- 
able resistance. 

At one time he was inclined to stand on the floor of the 
halls during long periods, and refused to sit down when 
requested, and in various other ways, such as refusing to 
take food until he was fed with a stomach tube, exhibited a 
disposition to be contrary. Afterward he became capricious, 
mischievous, and disorderly, and when required to take food 
would swear and cry and shout for a long time. He 
became destructive of books, plants, and furniture in the 
hall, and required to be vesicated on account of the habit 
of masturbation. During the month of June, 188-, there 
occurred a profuse discharge of pus from his left ear, which 
was attended with considerable pain and constitutional dis- 
turbance, and continued during several days. He remained 
in a decidedly improved condition after this for about two 
months, but then relapsed into his former condition. Dur- 
ing the last year he has alternated between a condition 
of apathy and stupidity, in which he is very reserved and 
moody, never engaging in games or conversation, and 
replies to questions only by saying, " Don't know ! " and a 
state in which he is mischievous and unruly, and inclined 
to annoy everybody with whom he comes in contact. 
During this time he has grown in stature considerably, but 
has not improved mentally. His mother visited him, but 
he would scarcely recognize her, and throughout the inter- 
view preserved an apathetic and stupid attitude. The 
25 



29O LECTURES ON MENTAL DISEASES. 

habit of masturbation, which he is inclined to practice, is a 
consequence, and not a cause, of his insanity. 

Case 4. — F. W. S., aged sixteen, son of a laborer, dark 
complexioned, and small in person, was admitted in 188-, 
with the statement that some three weeks previous he had 
wandered from home in a confused state of mind, and 
placed some ties upon the railroad track, with the purpose 
of wrecking trains. He was arrested, placed in jail, and on 
examination pronounced insane, his father stating that he 
had several times on former occasions left home in a con- 
fused condition, and wandered away a considerable distance, 
on one occasion being found some twenty -seven miles from 
home. When in jail he became somewhat excited and 
endeavored to escape from the room when any one entered. 
On admission he was much confused in answers to ques- 
tions, slow of speech and mental action, and had an impaired 
memory, but no delusions so far as could be ascertained. 
His replies to questions were made willingly, but very 
slowly and with manifest effort ; said he did not remember 
where he was born, and had no recollection of having 
placed the ties upon the railroad track ; was inclined to be 
taciturn, and to remain by himself apart from the other 
patients. After a few days he became intolerant of author- 
ity and defiant when remonstrated with ; was much inclined 
to annoy other patients and seemed to take pleasure in 
doing so; was quarrelsome and impudent in his bearing, and 
took on airs of much importance, treating the other 
patients with disdain and contempt. Three or four weeks 
later he became quiet and respectful, and assisted about 
the hall, and afterward was employed to some extent about 
the grounds outside, where other patients were employed, 
and when so occupied made his escape. 



ADOLESCENT INSANITY. 29 1 

He was returned to the institution after an absence of 
three months, during which he led a very unsatisfactory 
mode of life; a part of the time he was with his father, and 
the remainder with an uncle, but nowhere able to conduct 
himself properly ; but, on the contrary, was constantly get- 
ting into trouble with persons with whom he associated. He 
had a deep wound over the left eye, received while in a quar- 
rel which grew out of his insolence. After his readmission 
he was very restless, irritable and complaining at times, and 
on other occasions swaggering, quarrelsome. These con- 
ditions of mild excitement, attended with unreasonable con- 
duct and a disposition to annoy and quarrel with others, 
alternating with those in which he conducted himself in a 
respectful manner, have continued until the present time. 
He has now been for a longer period in a favorable state 
of mind than at any time since his admission. 

It will be observed that in no one of the cases detailed has 
there existed a condition of acute mania or of acute melan- 
cholia ; indeed, there has not been a symptom of much 
depression even, with one exception for a short time. 
During the progress of the cases there have been periods 
in which a measure of good feeling has existed, and a 
tendency toward mild excitement, also mental confusion 
with loss of memory, but in the case of none of the patients 
who have come under observation has this passed over 
into a fully developed condition of mania extending over 
any considerable period of time. 

In none of the cases have fixed delusions or hallucina- 
tions of any of the special senses been present. Some of 
the patients have been unable to realize where they were, 
and evidently thought they were in some other place than 
a hospital. The memory has generally been weakened, 
and the action of the mental faculties largely impaired. It 



292 LECTURES ON MENTAL DISEASES. 

was difficult to arouse the attention, and impossible to get 
the patients interested in reading, games, or, indeed, in any- 
thing until after convalescence had become fully established. 
Whatever excitement existed during the early stage of the 
attack soon subsided, and the patient passed into a stage of 
hebetude and partial dementia, though able to reply intel- 
ligently to questions when sufficiently aroused to under- 
stand them. This condition changed at times, in the males, 
into one of irritability, with a tendency to self-importance 
and quarrelsomeness, leading to blows ; at other times a 
disposition to complain of neglect on imaginary grounds. 
The sexual centres of the brain became unduly excited and 
sensitive, which led to the practice of masturbation and 
some of its more immediate consequences. 

The two cases now to be presented will illustrate the 
mental condition when occurring in older patients with 
more fully developed brain centres. It will be observed 
that in both the state of excitement was more marked, and 
of longer duration, and it was not succeeded by a condition 
of stupor. 

Case 5. — F. J. C, aged eighteen, has a high-tempered 
father, and a nervous, irritable mother. His knee is 
anchylosed, the result of abscesses which occurred when 
about eighteen months old. The disorder is said to have 
existed about .two years ; in this time he has had several 
periods during which he has been restless, obstreperous, 
and violent, and imagined that he was a dictator, and that 
his special mission was to see that the laws were not vio- 
lated ; was frequently at variance with his father, and others 
who sought to control him. When admitted there appeared 
to be a wasting of the muscles about the left hip, which 
was due, in part or wholly, to the weakness of the knee 
which is anchylosed. He was much elated and disposed 



ADOLESCENT INSANITY. 293 

to talk about his mission as a detective, and especially that 
he was to see that the Sunday laws were well observed ; 
appeared to have no apprehension of his true condition, 
but claimed that his violent conduct toward his father was 
all his father's fault, and wished to know if he could soon 
return home. He was often boisterous at the table, and 
extravagant in his statements ; had a troublesome cough, 
for which medicine was given. A few days after his admis- 
sion he became suspicious and thought his food was 
poisoned, and shortly afterward became more restless, 
walking about the hall the most of the day, very over- 
bearing and insolent toward the attendants and others ; 
used profane language, and did not sleep well for a consid- 
erable period. There was at no time an extreme degree 
of excitement, but he remained more than usually talkative 
and at times became rambling and incoherent. He rapidly 
lost flesh and strength ; the cough increased, and some 
ulcers appeared on his legs. These disappeared after a few 
months, and the mind became less confused, though still 
very slow and dull ; he rarely referred to his delusions and 
became pleasant in his relations to the attendants, and 
made some effort to aid himself. Still, his mind has not 
cleared up; he is restless at times, and at other times con- 
fused, and unable to apprehend and reply to remarks 
except in monosyllables. The secretions of the body are 
all as inactive as his mind, and he requires much attention 
and care. 

Case 6. — G. M., aged eighteen, was admitted to Retreat 
in 187- She had once before been a patient in an institu- 
tion for a few months. This time she came voluntarily with 
her sister, and appeared to realize that there was something 
the matter with her. She had recently become excited 
and restless and had walked three miles in the night, alone, 



294 LECTURES ON MENTAL DISEASES. 

leaving the house at twelve o'clock, to see the doctor. Was 
thin in flesh ; catamenia irregular. Had an aversion to 
members of her own family; had never attended school 
much, and had always been averse to discipline or study ; 
always got on better among strangers. After her admis- 
sion she conducted properly for the first few days, but 
before long became excitable, talkative, rolled on the floor 
in the hall, laughed in the chapel, and behaved in such a 
manner as to require removal. After a few days she became 
very mischievous ; endeavored to light papers and bits of 
cloth in the gas jet, and generally annoyed others in almost 
all conceivable ways. In October she began to pull out 
her hair, generally doing it in the night, until there was 
quite a large spot entirely denuded ; when expostulated 
with, said she wished to get rid of it. In conversation 
appeared to understand the bearing of what was said to 
her ; replied quietly to all questions, but claimed that she 
did not know why she removed her clothing, pulled out her 
hair, and destroyed about everything she could get her 
hands on. In March she became more amiable and less 
destructive, and to encourage her was placed on one of the 
best halls, in a room the door of which was opposite one of 
the gas fixtures in the hall. The gas was usually left burn- 
ing at this place, during the night, with a low flame. The 
second night at about ten o'clock, after all had retired, as 
she supposed, one of the attendants, who was near her 
room, heard a slight noise, and soon observed a long roll 
of paper projecting through the transom over the door ot 
this patient's room. It appears she had taken a news- 
paper, and after tearing it into slips, had twisted them 
into a roll more than a yard in length, and was pushing 
it out to light it in the gas. Not long after this she began 
again to remove her clothing, and so persistently that she 



ADOLESCENT INSANITY. 295 

was removed from the hall to another, and where she 
could pass out and into a large yard. She used to 
like to have her food, while here, in one of the summer 
houses, and was gratified in this respect by the attendant. 
The second day, while at dinner, she managed to climb 
over a fence some ten feet in height, and disappeared. 
Notice was given within a very few minutes, and search 
was made in all directions, but without avail. The next 
day (Sunday) a telephonic message was received from a 
neighboring town, inquiring if any one of our patients was 
missing. It appears that she had passed directly through 
the city, and had walked all the way up the railroad and 
through the town to the small house of a laborer, arriving 
there about sunset, and inquired if she could remain all 
night ; was made welcome, and at once began to make her- 
self useful by caring for a baby in the house. She care- 
fully avoided saying anything to indicate where she had 
come from, and appeared to be very well ; but the scanty 
amount of clothing she had on and her reticence led them 
to suspect that she might be from the Retreat. When 
called for, she stipulated certain conditions on which she 
would return, which were entirely reasonable, and at once 
acceded to. Within one day after her return she again 
began the round of excitement, destruction, denudation, 
and unnatural conduct. This continued for several weeks, 
when she rather suddenly began to improve, and at the 
end of a month returned home, where she has remained 
well since. She at no time gave indications of delusions, 
hallucinations, or dementia; her mind seemed to be re- 
markably active, easily excited, though the periods of 
excitement were not long protracted. 

It will be observed that in the female patients there has 
existed an absence or irregularity of the catamenia, and in 



296 LECTURES ON MENTAL DISEASES. 

two of the males a tendency toward the habit of mastur- 
bation. A similar statement could be made in regard to a 
majority of the cases of pubescent insanity which have 
been under my care. The question is suggested as to how 
far, if at all, the mental derangement is dependent upon the 
abnormal condition of the sexual system, or whether the 
latter is the result of the former? Probably in a large 
majority of cases the derangement of the sexual system 
exists as simply a concomitant, and not a cause, of the 
mental condition. 

It may be admitted that the mental function in the case 
of females may become clouded and imperfect in its expres- 
sion in consequence of a circulation of blood from which 
certain products of secondary metamorphosis have not 
been eliminated by the function of menstruation ; and also 
that a disorder of the central nervous system may cause an 
insufficient nervous energy in the sexual system to per- 
fectly establish the function of menstruation ; but these 
must be regarded as merely attendant conditions, or expres- 
sions of the disease. The fons et origo exists in the 
abnormal evolution of the several great nerve centres at 
the most critical period of life by reason of inheritance or 
faulty education. 

Allusion has already been made to the tendency toward 
relapses in adolescent insanity. There exists such a ten- 
dency during convalescence from mania and melancholia, 
and for a considerable period afterward, making it unad- 
visable to suddenly terminate asylum residence after the 
cessation of the acute symptoms ; but this tendency is more 
decided during convalescence from adolescent insanity 
which has its basis in an inherited neurosis. In a brain so 
burdened the inhibitory centres appear to regain their 
stability of action much more slowly. The whole nervous 



ADOLESCENT INSANITY. 297 

system is more sensitive to the effects of experiences of 
an unfavorable nature. The inhibitory centres are those 
which come into maturity of strength latest, and when 
they once become weakened and disordered in their 
activities the stamp of instability becomes greatly intensi- 
fied and may continue for years. 

Hence the danger of a too early removal from the asylum. 
The friends are only too ready to yield to the importunities 
of the patient as soon as he is able to realize that he is 
better and expresses a wish to go home. The frictions 
incident to every-day life outside are quite sure to exhaust 
the little store of inhibitory energy which has been acquired 
very soon, and a relapse occurs. 

Such cases cannot be regarded as recoveries. The 
unstable condition of brain centres continues to exist and 
relapses may occur from two to three years before the brain 
becomes fully restored. Indeed, this habit of brain may 
become permanently established, as it does in the case of 
epilepsy, so that it rarely or never again attains a perma- 
nent state of equilibrium. 

During these seasons of convalescence and while the cells 

of the cortex are still in a morbidly sensitive condition, there 

are two sexual activities which are very likely to act as 

exciting causes toward a relapse, even if they were not 

factors in the causation of the original attack. These are 

masturbation in the male and menstruation in the female. 

The occurrence of menstruation, which is usually absent 

during the acute stage, though a favorable indication of 

approaching recovery, yet necessarily entails a large drain 

for the time being upon the stock of nervous energy ; but 

the practice of masturbation acts much more efficiently 

through its effects upon the nerve centres, rendering them 

unstable and easily excited. The blood also becomes 
26 



298 LECTURES ON MENTAL DISEASES. 

greatly impoverished through the occurrence of both these 
experiences and this reacts upon the brain centres, causing 
sudden and irregular liberations of energy. 

The degree of mental excitement which may appear will 
depend largely upon the stage of recovery previously at- 
tained. Some patients will become talkative, boisterous, 
mischievous, and exhibit a tendency to injure those who 
may thwart their purposes; while others will become 
sullen, suspicious, morose, apathetic, and dull. It becomes 
impossible to predict from any present condition of mind 
which may exist what will be that of an hour or day 
hence. Such cases contribute largely to the number, 
who in after life have frequent admissions to asylums, 
or when not discharged are recorded as stationary. 

It should be stated that cases of adolescent insanity 
which make favorable recoveries are those who constitute 
the larger portion of persons who experience attacks of 
insanity at the other great epochs of life, viz, : the climac- 
teric and old age. 

Treatment. — One of the first and most important meas- 
ures in the treatment of pubescent insanity is removal from 
home and its associations to some institution. The moral 
effect of such a change is greater than in most other forms 
of insanity. It is the only means by which the patient's 
will may become supplemented by that of the physician's, 
to the end that a regular system of daily habits and 
experiences may be secured. 

Again : Regularity and a considerable amount of daily 
exercise or employment, if practicable, out-of-doors, should 
be secured, unless there exist contrary indications in the 
physical condition. This should be extended to producing 
physical fatigue. Restriction of general physical activities, 
and exercise in the open air, and confinement to seden- 



ADOLESCENT INSANITY. 299 

tary habits and employments at this period of life, have a 
tendency to awaken into activity any hitherto dormant 
tendency in the system toward any neurosis which may 
have been inherited. Such habits of life also tend to 
develop and bring into activity any tendency which may 
exist toward an excitement of the sexual organs, and the 
consequent habit of masturbation. 

These measures will prove sufficient in the majority of 
cases to secure sleep without the use of medicines for this 
purpose, which should be avoided if possible. 

In cases presenting an anaemic state, the system must be 
strengthened by the use of a sufficient amount of easily 
digested food used with regularity, tonic bitters, cod-liver 
oil, and some preparation of iron. These remedies will 
also be in order in those cases attended with menstrual 
deficiency or irregularities. Pills of iron and aloes may 
also be used at night as the patient approaches near to the 
monthly period, together with hot applications to the lower 
spine. 

What I have to add further in relation to the treatment 
of pubescent insanity will relate to its prophylaxis. Indeed, 
this may be regarded as of the highest importance in rela- 
tion to all children who inherit a predisposition to insanity 
or any of the neuroses, and relates to such a course of 
education, using this word in its broadest sense, as will 
tend to carry the child through this important period of 
physical and mental development with the least possible 
strain upon the nervous system. 

In the first place, the education of such children should 
be individual rather than general. Whatever may be said 
as to the efficiency and desirableness of the system of public 
schools for educating children who have sound, vigorous 
constitutions, cannot be regarded as true in the case of 



300 LECTURES ON MENTAL DISEASES. 

those whose inheritance is one of insanity. The primary 
object of all education should be to symmetrically develop 
all portions of the system, and thus to fit them for the most 
perfect exercise of their several functions. In this process 
no rule can be devised which will be applicable to all cases 
alike. There will be exceptions, and none of more impor- 
tance than those of persons now under consideration. A 
sound arm or leg may be made more strong by such active 
and oftentimes vigorous exercise as would ruin a weak or 
unsound one, and the exercise of such activities would 
only serve to develop and bring to light the weakness of 
such organ if it exist. In the same manner the strain of 
the brain incident to the race for an education in the public 
schools, with thirty or forty other pupils in the same class, 
all of whom are endeavoring to understand and absorb a 
multitude of dry facts and constructive propositions, is 
almost sure to develop any latent tendency which may 
exist in the brain into something more than a tendency. 
Such a brain, therefore, requires special attention in its 
training, rather than such as is necessarily incident to a 
large public school. 

Again, bearing in mind that in many of these cases the 
evolution of energy in the motor centres greatly exceeds 
that in the inhibitory centres, which leads to inordinate and 
aimless expenditures of nerve force, education should be 
directed toward training the hands and arms in the execu- 
tion of particular and definite movements. For this purpose 
nothing is better than lessons in drawing and learning some 
handicraft. This may be confined at first to the drawing ot 
simple lines, then of geometrical figures, and later may be 
advanced to the construction of small articles and regular 
work. In other words, the system of education should be 
industrial — a learning of how to do and make things, rather 



ADOLESCENT INSANITY. 3OI 

than how to remember facts. Education should also relate 
chiefly to the phenomena of an external world, such as is 
presented in natural history and science, and can be ob- 
served, rather than learned from books. The powers of 
observation rather than those of retention require special 
instruction and exercise. 

After all, there is much danger that in many of these 
cases there will be little systematic education, either general, 
individual, or industrial, except such as unfavorable ex- 
periences afford. The child fails to learn as other children 
learn ; he dislikes and fights against the restriction and dis- 
cipline sought to be enforced, and the parent is inclined — 
nay, too often is forced — to give up the idea of an education 
in school, and the child is left to run riot. It, therefore, 
becomes of the first importance that the will of the child be 
supplemented by that of others until the age of eighteen or 
twenty years, and that the psychical centres be educated, 
as far as they can be educated at all, mainly through the 
discipline of the motor centres, in the regular performance 
of some form of lisrht manual labor. 



LECTURE XVI. 



SENILE INSANITY. 

Old Age — Characteristics of — Evolution No Longer Keeps Pace with Involu- 
tion — ^Etiology — Physiological and Pathological Changes in Brain and 
Nervous System — Diminution of Functional Activity — Vascular Changes 
— Nerve-cells — Mental Symptoms — Impairment of Perception — Excite- 
ment — Loss of Memory — Illusions — Depression — Physical Symptoms — 
Three Varieties — Senile Dementia — Senile Mania — Senile Melancholia — 
Cases Illustrative — Suicidal Tendencies — Treatment — Should Such Cases 
be Removed to an Asylum ? — Testamentary Capacity. 

Old Age. — Age is a relative matter and not a question 
merely of the number of years one may have lived. While 
some persons become old at fifty or sixty, others are active 
and vigorous at sixty-five or seventy. The periods of 
youth and middle age are associated in our minds with 
activity and enterprise ; old age with quiet and rest ; the one 
with anticipation, expectancy, confidence ; the other with 
retrospection, doubt, and a tendency to believe, that the 
former days were far better than the present. In middle 
life the mind displays its largest activity, greatest endur- 
ance, and soundest judgment. Yet there exist all degrees 
of activity and endurance even in this period. Some 
people seem to have been born old, and never to become 
young. Their movements, both mental and physical, are 
moderate, and they go through life at a snail's pace. The 
cell batteries connected with motor and mental activities 
generate force lazily, and soon become exhausted. Race, 

302 



SENILE INSANITY. 303 

heredity, and environment have much influence in this, as 
in all other respects, in determining characteristics ; the 
slow Turk and Asiatic repeat themselves and grow old 
slowly. But in the midst of the modern requirements of 
living, necessity often proves a severe master, and drives 
with both whip and spur, while the length of time occupied 
in expending the unit of vital force depends upon the rate 
of speed kept up. The child sent on the street at five or 
six years of age, to hawk about matches, pins, or news- 
papers until ten o'clock at night, day after day, half fed, and 
poorly clad, will pretty surely become old while yet young, 
unless he dies too soon for this to take place. 

Old age means that the process of evolution no longer 
keeps pace with the opposite process of involution. 
There exists a period in life when the two counterbalance 
each other, and the system moves on, maintaining its own, 
and capable of large expenditures of nervous energy in 
many directions. In old age this adjustment no longer 
continues; but, on the contrary, there exists a diminution 
of all the forces of the system, and it gravitates earthward. 
Generally the brain is the last organ in the system to 
participate in this downward course. As in youth it is the 
last to mature and become strong, and its highest faculties 
are the latest in development, so in the period of decline, 
it generally exhibits failure later than other organs, except 
from the effects of adventitious disease. When, however, 
the process of degeneration begins, those faculties which 
are the highest and last to develop are generally the first to 
fail. Imagination, and its outcome, expectancy, in a large 
degree cease to exist, and the individual tends toward a 
life in the retrospect and introspect, and he again lives over 
the years long since past. 

Spontaneity in inception and purpose no longer exists. 



304 LECTURES ON MENTAL DISEASES. 

Habits which are the outgrowth of the observation and 
experiences of past life determine the course of action, 
more than influences which arise from present experiences. 
The emotions and aspirations toward something higher and 
larger in the relations of life, which may have produced a 
determining motive toward courses of conduct, are now no 
longer present. 

Not unfrequently the individual himself is the last to 
discover and appreciate his own weakness and the on- 
coming of decay. He still clings to the belief that he can 
endure and execute as in the past, and any suggestions to 
the contrary encounter incredulity and quick opposition. 
Self-confidence, irritability, and eccentricities of all kinds 
tend to increase as ability diminishes. The brain becomes 
less capable of protracted application and sooner gives 
evidence of exhaustion. It requires longer and more 
frequent periods of repose and sleep. The individual 
inclines to hold with a strong grasp to the traditions 
and associations of the past, and when he has been largely 
absorbed in the accumulation of property, not infrequently 
degenerates into the true miser, and runs his little round 
of daily activity in counting over his much or little of the 
results of life's work. Such seems to be the natural order 
in the course of old age, and may exist without the indi- 
vidual being regarded as either insane or technically 
demented. But a stage arrives in the lives of many when 
they move on into conditions further advanced, and which 
must be regarded as resulting from true pathological 
changes in the brain. 

Etiology. — At first thought we might conclude that 
insanity is less likely to occur in old age than during the 
younger period of life, and this is doubtless true in rela- 
tion to some forms of disease. What may be termed the 



SENILE INSANITY. 305 

moral causes of insanity are probably much less potent 
than in middle life. The brain and the whole nervous 
system are much less sensitive, and consequently are less 
affected by the annoyances and irritation arising from the 
friction of every-day experiences ; impressions of all kinds 
are less enduring, and persons have generally learned from 
the outcome of past experiences to accept disappointment 
as largely the lot of everybody. There no longer exists 
much doubt as to the course of conduct to be pursued, 
'opinions to hold, or beliefs to be entertained. Quarrels 
and differences of opinion, instead of causing regrets, 
questionings, and uncertainties in the mind, only tend to 
confirm and settle it in the course to be followed out. Even 
the loss of children and companions by death is accepted 
with less of mental suffering than when occurring in middle 
life. So far, therefore, as such experiences ordinarily act 
as causes of insanity, they are greatly lessened in old age; 
but certain changes in the brain itself may, and not infre- 
quently do occur, which so far affect its activity as to render 
the individual incapable of properly conducting his own 
affairs. 

It will be observed that the changes in the mind already 
referred to result largely from a diminution of functional 
activity, such as would ordinarily ensue from a lessening of 
the vital force of the system in old age. Those now to be 
referred to indicate not only failure, or diminution of activ- 
ity, but irregularity and imperfection. These pathological 
changes relate chiefly to the blood-vessels, nerve cells, 
and interstitial tissue of the cortex of the brain. As 
the vital energy of the system diminishes, this is manifested 
in the capillary system of the blood-vessels of the grey 
matter, primarily in a thinning and consequent distention 
of their coats. In consequence of the occurrence of this 



306 LECTURES ON MENTAL DISEASES. 

condition, the bioplastic material, which in a state of health 
is received into and becomes organized as a constituent 
portion of the vessels, passes into them and becomes 
irregularly deposited, btit is not absorbed and organized. 
On the contrary, it dies, that is, becomes resolved into the 
elements of fat and fibrin, and acts as a source of irritation, 
and consequent thickening of the coats of the vessels in 
various localities. This is usually termed atheromatous 
degeneration of the vessels, and serves greatly to impede 
those physiological activities which are constantly going 
on in a condition of health. As a result of this irregular 
thickening, the caliber of the vessels becomes lessened, 
and consequently the volume of blood passing through 
them, and there must result an impoverishment of those 
parts which have before been supplied. 

The nerve cells, more particularly the large pyramidal 
cells, are especially sensitive to this change. Their func- 
tional activity, depending, as it does, upon the blood- 
supply, becomes lessened when this is diminished, and 
ultimately the constitution of the cells themselves becomes 
changed. They are smaller as well as fewer in number ; 
change in form, becoming less angular and more round, 
and the length of inter-nerve space becomes increased. 
Marked changes in the smaller oval cells are less pro- 
nounced. While there occurs a shrinking of the whole 
volume of the brain, it is more pronounced in the frontal 
and parietal regions than in the occipital lobe. 

Referring again to the capillary vessels, we find that 
in consequence of the degeneration which takes place in 
their coats localized softenings and minute ruptures occur, 
with slight extravasations of the blood or serum, which 
act as irritants and excitants in the motor areas of the 
brain. These occur not only in the cortex, but also in 



SENILE INSANITY. 307 

the ganglia of the optic thalami and the corpora striata. 
They vary in size from minute points to the sixteenth of an 
inch in diameter, and in proportion to their size and locality 
exert pressure and irritation upon the contiguous parts. 
They, however, occasion less disturbance of both mental 
and motor action, and their effects sooner pass off, than 
would result at earlier periods of life ; probably there is less 
sensitiveness of the brain itself in old age. Not unfre- 
quently small thrombi are formed on and remain at the 
thickened portion of the vessels, which totally occlude 
them, and cause a degeneration or necrosis of those ele- 
ments beyond, which before had been supplied. As a 
result of these changes in the vascular system of the brain, 
which are more numerous in the white than in the grey 
substance, its volume becomes much lessened. The dura 
mater is often thickened. The arachnoid and pia mater 
are also thickened, though the latter is not adherent to the 
cortex, as in general paresis. These thickenings and the 
effusion between the membranes occupy the otherwise 
vacant space and tend to compensate, at least in part, for the 
shrinkage of the brain. 

It should be said that we are not yet able to demonstrate 
that these changes in the brain are the direct cause of 
attacks of pronounced insanity in the senile brain. That 
they arise and progress pari passu with the ordinary mental 
decay of old age there can be no doubt ; nor do I think there 
exists any reasonable doubt that the disturbances of brain 
tissues which are incident to their occurrence constitute the 
proximate cause of attacks of insanity. But I am not aware 
that we yet have definite and absolute proof of this. We 
still require observations relating to the changes in the 
elements of brain tissues which pertain to the decay of old 
age and to the insanities incident to it. 



308 LECTURES ON MENTAL DISEASES. 

The brain, however, is not alone in this process of atrophy. 
The whole body and all its organs sympathize with it. The 
face becomes less full, and the body less round and more 
stooping and angular ; the eyes become sunken ; the skin 
dry and hard ; the scalp bald and thin ; the soft parts about 
the lower portion of the face and neck partially relaxed, and 
words are no longer articulated with the distinctness of 
younger years. In short, the whole physical system and 
the involution of its visceral functions and movements keep 
pace together on the downward journey. 

Mental Symptoms. — In consequence of the above-men- 
tioned pathological changes in the vessels and tissues of the 
brain, the blood is not returned to the lungs so freely and 
regularly for purposes of oxygenation, and the effete pro- 
ducts are not so thoroughly removed ; the molecular changes, 
which are the concomitants of all nervous action, become 
impeded. Hence, what was a consequence of imperfect 
action becomes a cause of greater imperfection of activity, 
which is manifested in the mind, in some cases, by impair- 
ment of perception and the various processes of thought. 
The mind takes cognizance of the external world and the 
various interests and affairs of society with less accuracy and 
readiness ; the power of comparing and rejecting, or com- 
bining ideas, so as to form opinions and motives of action, 
becomes lessened, and, in consequence, the faculty we call 
judgment is impaired; the person is likely to make mis- 
takes, especially in reference to property and business. The 
delicacy of relations toward others is not so fully realized 
and appreciated, and hence the increase of friction arising 
from the daily associations with the younger members of 
family life. 

Again, the pathological changes above referred to in 
certain areas of the brain sometimes tend to produce an 



SENILE INSANITY. 3O9 

increase of function during short periods in other limited 
sections. This frequently leads to exhilarated feelings, with 
an overweening" degree of confidence, and the individual is 
perfectly sure that he was never more able to understand 
and prosecute new or large enterprises in his life ; he is 
confident he understands how he can easily double his 
fortune, conduct successfully the affairs of a new family, 
or wend his way without difficulty through the tangled 
web of political life, if he can only succeed in securing an 
opportunity of doing so. This exalted state of feeling and 
excessive confidence is generally one of ominous import, 
and indicates the near approach of more pronounced 
disorder. In case the person is widowed, he not unfre- 
quently proposes to some person young enough to be 
his granddaughter, or possibly to the servant girl in his 
own house, and against the protest of his children and 
friends he persists in marrying her, and often disinheriting 
his own children in favor of his new alliance. In other 
cases the sexual tendency becomes so pronounced that the 
patient disregards all forms of decency, and gives the lie to 
the experience of a life of the highest character and respect, 
before his family realize that he is insane. 

The memory generally fails first, and more especially 
in relation to daily and hourly experiences and transac- 
tions. The individual cannot tell the day of the week or 
the month of the year. He does not remember the names 
of his own children, or those of his friends and neighbors ; 
whether he has paid a bill, or been paid ; and later on in 
the progress of the disease, he fails to recognize the mem- 
bers of his family ; loses his way on the street ; does not 
know his own house when he sees it ; frequently insists 
that he is not in his own home and demands to be 
permitted to go there ; becomes suspicious of those about 



3IO LECTURES ON MENTAL DISEASES. 

him ; thinks they are strangers, and are trying to rob and 
plunder him ; has illusions of sight, and thinks persons 
whom he sees are others whom he saw years before, and 
insists upon calling them by some names heard and re- 
membered long ago; frequently has perverted sensations, 
as of cold when the weather is hot; and will insist upon 
having a fire made in July, or in putting on quantities of 
thick clothing when everybody is sweltering with the heat, 
and when the weather is cold in going out without extra 
protection. 

The susceptibility of the physical basis of recent memories 
is greatly impaired, and the mind has a very limited 
influence over it, while the memories of former years still 
remain quite distinct, and unconsciously arise into recollec- 
tion. The memory of heat or cold presenting itself in 
consciousness, the patient, without ability to compare his 
past experience with the present by association of ideas, 
acts automatically, or nearly so, under the stimulus of the 
remembered sensation. 

The failure in memory, the perverted sensations, imper- 
fect perceptions and illusions, render such persons in an 
institution, or anywhere else, exceedingly troublesome, so 
that they require constant care and supervision. They 
are all the while getting into other persons' rooms and 
failing to find their own ; they mistake the fireplace for a 
urinal, and a lavatory for a water-closet ; they soil their 
clothes and beds ; become obstinate and apparently resent- 
ful of all that is tried to be done for them ; will insist 
upon getting out of bed, especially at night, pull the 
clothes and mattress off, and pile everything up in a corner 
of the room ; move the bed against the door ; pull down 
the curtain of the window, if there is any to pull down ; 
shout and scream that robbers are about ; that they are 



SENILE INSANITY. 3II 

being killed ; and when one comes to their aid, will strike 
and kick and resist to the very last every effort to assist 
them to a better understanding and experience of their 
surroundings, under the impression that they are defend- 
ing themselves. 

Physical Conditions. — The physical conditions as to 
strength and agility change greatly from time to time, and 
appear to have some correspondence to the excited or 
depressed states of the mind. The amount of physical 
energy and endurance which some old men, who appear 
to be just ready to topple over into the grave to-day, may 
exhibit next week, while under the influence of marked 
changes which will occur in the brain and the resultant 
impressions and delusions, is very remarkable. They rarely 
remember anything about it after the period of excitement, 
or the force of the hallucinations which gave rise to it, has 
passed away. At other times they sit for hours wherever 
they are placed, or lie in bed saying nothing and with 
difficulty understanding anything said to them. Some- 
times dim memories seem to flit across the mental hori- 
zon at the sound of some name or voice which has excited 
into vibration, or molecular activity, some channel of 
thought or nerve cell which has long been dormant or 
become half disintegrated. 

Recently one of our patients, H. F., whose son, who 
resides in Washington, was visiting him, turned suddenly 
and asked him where he was from; he replied, " Why, 
father, I am just from Washington." " Washington — Wash- 
ington !" repeated the father. " It seems to me that I once 
had a son there in some important position ; wonder if you 
knew him ? " and continued gazing vacantly upon the wall 
of the room before him. 

Senile insanity presents a considerable variety in its 



312 LECTURES ON MENTAL DISEASES. 

manifestations in different cases, and in the same case 
in different stages. While many exhibit a condition bor- 
dering upon mental vacuity (senile dementia) month 
after month, and seem to be incapable of being roused or 
excited in any degree or by any cause, others exhibit 
more or less depression, restlessness, and opposition at 
times, more especially after an apoplectic attack ; while 
others still have periods of acute excitement attended with 
delusions and hallucinations. Senile mania runs a more 
or less limited course, and then the patient may recover, or 
pass into a condition presenting such symptoms as attend 
other cases of the first or second class. The following 
cases will serve as illustrations, more or less fully, of the 
three forms which senile insanity may present : — 

The first case, S. F., is past ninety years of age, and is 
dressed every morning and night like any little child, and 
taken from and put into bed. She sits from morning to 
night in her chair (except as she is led from one room to 
another by the attendant), holding a little doll in her arms, 
and every now and then turning upon it an affectionate and 
motherly look (she was never married). When addressed 
she looks up and sometimes smiles, especially when her 
doll is praised, but never utters a sentence, or speaks more 
than one or two words, sometimes saying, "yes," or " no." 
She has neither delusions, hallucinations, excitement, nor 
depression, though there may be illusions of sight which 
lead to her conduct in relation to the doll, and rarely gives 
any evidence of the power of recalling memories. 

The hair has never lessened on her head, and has grown 
quite abundant about her lips and chin, and she is never 
without a vacant look or stare, except when she pets, in 
her own peculiar way, her little doll. She has had during 
the past year slight apoplectic attacks as often as once in 



SENILE INSANITY. 3I3 

two or three weeks. During these attacks she lies with 
eyes sometimes closed, and at others open, breathing with 
a slight blowing movement of the cheeks and lips. The 
pulse is generally increased in frequency and volume, and 
one side or the other is partially paralyzed. The effects 
usually pass off after two or three days (sometimes more 
quickly), and she again resumes the round of her daily 
life in her chair and with her doll. This rests upon her 
arm at night in her sleep, arranged as a mother would ar- 
range her nursing child. Evidently this doll has touched 
the profoundest, and, indeed, the only, chord of her nature 
which is capable of being touched or of responding to any- 
thing. The apoplectic attacks are evidently caused by the 
rupture of some minute vessel, and the extravasation of a 
slight quantity of either serum or blood ; and if we could 
examine the brain structure, we should find, doubtless, 
many of the remains of these minute hemorrhages through- 
out the cortex, some of which have become partially 
absorbed, and others sacculated and remaining as sources 
of more or less irritation. The irritation would be much 
greater in a younger and more sensitive brain, and remain 
during a longer period. It is probable, also, that these 
seizures may occur in severe cases of senile degeneration 
without demonstrable anatomical lesions. The apoplectic 
attacks continued and increased in frequency and severity 
until she died in one of them, in the ninety-third year of 
her age. 

Similar convulsive attacks occur in about ten per cent, 
of all cases of senile insanity. 

The next case, C. A., presents another phase of the 
disease, which differs very materially from the one just 
mentioned, and which will illustrate the character of mani- 
acal attacks in a senile brain. He is eighty-two years of 
27 



314 LECTURES ON MENTAL DISEASES. 

age, has been a man of active habits, and during many years 
the captain of a coasting vessel. He has exhibited indica- 
tions of more or less mental decay for several years past, 
but has lived with his family until recently, when he became 
so irritable and unreasonable in his demands and general 
conduct, exhibiting a disposition to strike any one who 
opposed or neglected to comply with his demands, that his 
friends were obliged to send him from home. He does not 
realize at the present time where he is, but refers to this 
place as the one in which he resides when at home. He 
walks with much difficulty, and is obliged to be assisted to 
and from his room, and is partially aphasic. A few nights 
since he experienced an apoplectic attack, and remained 
unconscious during two days; he then began to regain his 
consciousness and to move about on the bed. Two days 
later he succeeded in getting up, pulled his mattress on the 
floor, and moved his bedstead against the door. He has 
been careless and dirty in the extreme the most of the time 
before and since the fit ; resists about everything the at- 
tendant tries to do for him, exhibiting much more physical 
strength than he appears to have ; he is very profane and 
noisy, especially at night, and causes more annoyance, and 
requires more attention, than all the other patients on the 
hall. When free from excitement he appears feeble and as 
if he would not live a week, but when excited, the strength 
of his movements and the vigor of his voice indicate any- 
thing but exhaustion. He does not remember anything 
from one hour to another, and within a few minutes after 
dinner cannot tell whether he has had it or not. At times 
he will speak of things that occurred many years ago, 
apparently with an accurate recollection. Not long since 
he began to talk about his will, and said that by its provi- 
sions he had left all his property to his present wife and her 



SENILE INSANITY. 315 

children, but had left none to the children of a former wife. 
Having got off so much with tolerable clearness, he became 
confused in thought and utterance and unintelligible, 
began to shed tears, and soon to mutter about something 
else, and since then has never referred to the subject, or 
clearly to any other. The disposal of his property in this 
manner had evidently caused him some anxiety when he 
made his will, and now for a moment the subject came 
again into consciousness, but soon vanished in the con- 
fusion and weakness of his mental activity. 

There is another case, F. H., on the same hall as T. A., 
whose condition is somewhat different. During the larger 
portion of the time he will sit in his chair from morning 
to night, except as he is taken to his room or to the dining 
table, saying little or nothing. But during the two years 
since his admission to the Retreat there have been several 
occasions during which he has been quite excited. At these 
times his leading delusion is that some one is being killed ; 
he then shouts at the windows and begs to be taken home ; 
is thoroughly confused in his mental operations, and is con- 
stantly appropriating articles belonging to other patients. 

This excited state continues only two or three days, 
when he relapses again into his state of dementia and men- 
tal inactivity. These periods of excitement probably arise 
from changes in the circulation in certain areas of the 
cortex or the central ganglia, or from the irritation which 
results from pathological changes which are frequently 
taking place in these portions of the brain ; and as the 
senile brain soon becomes tolerant of the changed condi- 
tions if they are not too great, the irritation becomes less, 
and the outward expression of it in the form of increased 
motor activity, restlessness, and shouting also subsides. 

The fourth case had an attack of melancholia with delu- 



3 16 LECTURES ON MENTAL DISEASES. 

sions, which passed through a more or less definite course 
with an ending in recovery, but with conditions usually 
present in senile decay. 

C. A. A., aged sixty-eight, was admitted with the state- 
ment that he had been failing in strength and activity for 
some years past, but had never been able to realize it ; has 
thought that he could do just as much as in former years, 
and became greatly annoyed by any insinuations to the 
contrary ; has persisted in trying to dictate how the men 
on the farm should do the work, and in showing them how 
to do it himself. A few months ago he lost his self-confi- 
dence, began to fear that his property was all gone, and 
that he was to go to the poorhouse ; that persons were 
trying to rob him ; threatened to kill his wife, and recently 
wished himself dead, and made one or two attempts at 
suicide, which led to his being brought to the Retreat. 
He is now restless and uneasy, walks the hall, often sheds 
tears, and wishes to be returned home ; is very suspicious ; 
has hallucinations of hearing ; says the poorhouse is the 
place for him ; that he can never pay for being here, etc., etc. 

Under the influence of the treatment and regularity of 
the Retreat life, he began to improve ; his despondency be- 
came less ; the hallucinations ceased ; he took an abundance 
of nourishing food, and in a few months returned home 
quite happy, but still with the enfeebled mind of an old 
man. This case, so widely different from the cases of S. 
T. and C. A., is simply one in which there came on an 
attack of acute melancholia in an old brain. While there 
existed an enfeebled and imperfect mental condition both 
before and subsequently to the attack, yet there was not such 
a state as is implied by the term senile dementia, which is 
the sequel of irreparable loss of nerve energy or more pro- 
nounced pathological changes in the brain with atrophy. 



SENILE INSANITY. 317 

The fifth case to be mentioned is in the Retreat at the 
present time of writing. It illustrates a senile form of 
melancholia, connected with brain atrophy, from which 
patients do not recover. 

He has been under observation six years, and during 
that time has passed more than five years in a condition of 
mental and physical depression. He is now seventy-four 
years of age, of light, sandy complexion, thin in flesh, un- 
stable in gait, somewhat anaemic, with feeble action of the 
heart. He experienced one or more periods of depression 
several years ago, but was never placed in an institution 
for treatment. 

During his residence at the Retreat, he has never, on any 
occasion, been especially exhilarated or happy, but, on the 
contrary, all the while self-accusatory, and reproaching him- 
self for past delinquencies, for which he says he has never 
been forgiven, and for which he fears he will be eternally 
punished. The secretions are rather scanty, and he rarely 
takes any satisfaction in the use of food, which he takes 
only as a duty. 

He has often told me he would like to die, and the suicidal 
intent is evidently frequently present, but he has not the 
courage to execute it, and says he is really afraid to die, but 
would do so if he dared. Sometimes he confidentially asks 
me if I am willing he should longer remain at the Retreat, 
and when asked what reason he has for supposing that I 
do not desire him to do so, replies that he has been such a 
hypocrite and sham all his life that he cannot believe that I 
wish to see him about. 

At the present time the mind acts very slowly, and there 
is little if any ability to associate ideas together so as to 
form a definite opinion about any subject. He can refer 
with some accuracy to events which occurred years ago, 



3 1 8 LECTURES ON MENTAL DISEASES. 

but has little capacity for registering the events of yester- 
day. The action of the mind is largely automatic, and he 
lacks the ability to reason about any plan or question which 
may be suggested to him for decision. 

There is no history of alcoholism, but, on the contrary, 
one of great regularity as to habits of life. He is becoming 
more and more insensible to passing events, which seem to 
become blended with former experiences, which he some- 
times refers to as if they had only just now occurred. The 
process of involution is steadily and slowly going forward, 
and he will, if he lives long enough, ultimately become as 
feeble in mind and body as the first case described. 

During the last two years he has had epileptiform 
seizures of a mild character, three or four times a year. He 
generally remains in bed, however, only a few days, and 
appears less despondent after recovering from the imme- 
diate effects of an attack than before. While he has had 
short periods of being almost free from depression, yet he 
has never been entirely so, and never confident that he 
could with safety to himself leave the Retreat. 

The suicidal tendency is present at times in a large pro- 
portion of such cases. 

It will be observed from the study of the senile cases in 
almost any institution, of which those above outlined may 
be regarded as specimens, that the symptoms of senile 
insanity present a large diversity. They may prove to be 
those of dementia which is the result of slow and long- 
continued degenerative changes in the system, with conse- 
quent diminution or loss of nerve energy, in which case 
the patient finally dies in a state of fatuity. 

Or, again, the symptoms may consist in simple excite- 
ment, increased motor activity, loquacity, and self-confi- 
dence, all of which may subside after a few weeks ; or, on 



SENILE INSANITY. 3I9 

the other hand, may become greatly exaggerated, until the 
patient is noisy, incoherent, and rambling in thought and 
speech, and unable to sleep or remain quiet for any length 
of time. Such patients often refuse to take food and are 
likely to die of exhaustion unless the acuteness o( the 
symptoms becomes less pronounced. All these mental 
states may subside and the patient recover a considerable 
degree of mental soundness, or he may pass into a state ol 
confirmed senile dementia. 

Finally, the symptoms may from the first assume a 
depressive or melancholic type, and the patient, so far as 
he is fully conscious, becomes absorbed in reflections 
which are of a painful nature, and often has impulsive 
tendencies. At a later stage the mind may pass into a 
condition of reverie or be lost in a state of torpidity with 
little indication of volition, or of attempts to recall the past, 
or to initiate any course of action or thought, unless it may 
be one of self-injury or destruction. Not unfrequently the 
general condition of melancholia is attended with short 
periods of maniacal excitement and destructive tendencies. 

The treatment, or rather the course to be adopted in 
the management of some cases of senile insanity, may 
become one of much delicacy. If the person is one who is 
likely to be benefited or cured by treatment in a Hospital 
for the insane, the duty of an early removal, as in cases of 
other forms of insanity, is evident, but in the majority of 
these cases there exists little prospect of recovery. The 
question, therefore, resolves itself into one of care; and it is 
one often presenting a good deal of embarrassment. It is 
no light thing to remove an old man or woman from the 
scenes and surroundings of a home, where long years have 
been spent, and which, in many cases, is the result of years 
of labor, to any public institution, and from the presence of 



320 LECTURES ON MENTAL DISEASES. 

children and neighbors, to that of entire strangers. It is 
certainly not too much to urge that great patience and for- 
bearance on the part of relatives be used toward this class 
of persons, and that every available resource be tried before 
removal. This was done in the case of F. H., referred to 
above, and a man was placed in charge of him for several 
months prior to his coming to the Retreat ; but he finally 
became so obstinate, and so much disposed to resist and 
strike every one who in any way opposed him, that his 
family became fearful lest he should actually do injury to 
those having the care of him. The course to be followed 
in such cases becomes evident. 

Again, there are many cases in which the friends have 
not the requisite means to provide for necessary attention 
at home, however much they may desire to do so. Under 
such circumstances the well-being and interests of the other 
members of the family must be consulted as well as those 
of the individual, and no greater kindness or good for the 
greater number can be done than by a removal to a public 
institution. But whether at home or in an asylum, the 
principal desideratum is skillful management and care. 
Medicine may be of temporary use in allaying excitement, 
if it exists, as in other forms of insanity, but a sunny, warm 
room in winter, with a bath-room attached or near at hand, 
together with a simple, and abundant dietary, comprise the 
requisites for proper care. 

Testamentary Capacity. — In one respect, senile in- 
sanity is the most important of any of the genera which 
we have to study; that is its relation to the disposition of 
estates. More wills, which have been executed after per- 
sons have exhibited indications of a diminution of mental 
capacity, have been contested for this reason than for any 
other. In some lay minds, any mental impairment means 



SENILE INSANITY. 321 

insanity, and when individual interests are at stake, it is 
remarkable how large, or how small, according as these 
interests may become affected, these early indications of 
impairment may become. 

It is important in this connection to bear in mind the 
distinction already made evident between the normality of 
old age and the different forms of senile insanity. It will 
not be safe to assume that because one has become infirm 
in body, and has given indications of diminished vigor of 
mind, or because he has exhibited senile eccentricities, and 
is quite determined to have his own way in spite of the 
desires of his friends and family, has periods of more or 
less irritability, and has not as good ability in business 
transactions as when younger; nor, again, because he has 
become retrospective in his mental tendencies, and thinks 
that the former times were better than the present, repeats 
the incidents and stories of his experience in other days, 
while he forgets more recent ones, — therefore he is incompe- 
tent to intelligently and properly dispose of his own property. 

On the other hand, only when the mind has become so 
far impaired, that the person is unable to properly under- 
stand the relation he sustains toward his heirs at law, or is 
influenced in his feelings toward them, or others, by delu- 
sions, or unjust suspicions and insistent ideas ; or when he 
becomes incapacitated to understand the immediate effects 
of his will upon the members of his family, or their respect- 
ive claims upon him, or his own duties and responsibilities 
toward them ; or, again, has been subject to undue or im- 
proper influences to such an extent as to will away his 
property from his legal heirs to others whose claims are 
not valid, or otherwise make wrong disposition of it, — will 
the Court be likely to decide that the person has not 
sufficient testamentary capacity. 
28 



LECTURE XVII. 



CLIMACTERIC INSANITY. 

./Etiology — The Epochs of Life — Relation to the Period of Involution — De- 
pendent Upon Physical Changes in the System — Diminution of Nerve 
Energy — Indifference — Loss of Appetite — Absence of Good Feeling — Pro- 
found Change in the Female System — Change in the Channels of Mental 
Activities and Sympathies — Changes in the Processes of Elimination — 
The Cessation of the Catamenia — Heredity— Symptoms — Melancholia — 
Case i — Conditions of Depression — Abnormal Sensations — Loss of Flesh 
— Recovery — Case 2 — Mother Insane — Very Suicidal — Convalescence — 
Recovery After Four Years — Delusions — Hallucinations — Physical Symp- 
toms Present — Cases 3 and 4 — Differentiated from Melancholia at After 
Periods of Life — Prognosis — Sixty Per Cent, of Cases in the Retreat Re- 
cover — Length of Time — Permanency of Recovery will Depend Largely 
upon the Antecedents of the Case — Treatment. 

^Etiology. — Having studied now those insanities 
which are connected with the two great epochs of life — 
pubescence and senility — we next proceed to the study of 
that connected with another epoch of life, which is of 
scarcely less importance, viz., — the Climacteric. These 
three forms have been grouped together, because they alike 
arise in connection with the great physiological epochs of 
life ; the genus now to be studied has been arranged as the 
final one, for the purpose of more clearly and definitely 
differentiating the main characters and symptoms of 
those already examined, and also for showing in what dis- 
tinctive manner they resemble and differ from one another. 
One of these insanities has been shown to be connected 

322 



CLIMACTERIC INSANITY. 323 

with, and in some measure to arise from, the processes of 
physical and mental functions, and the other from those 
changes which occur in connection with the processes of 
involution, or decay. The one now under consideration 
is proximately caused by changes in physiological activi- 
ties which occur only during that epoch which is termed 
the grand climacteric, and therefore differs in some 
degree, in its character and symptoms, from each of the 
other forms. While it is far removed from the period 
of evolution, and is in no degree connected with it, it 
does have a close relation to that of involution ; that is, 
it, so far as it depends upon predisposing causes aside from 
heredity, arises from those physiological changes which 
occur in a portion of the nervous system at the period 
which immediately precedes or coincides with the com- 
mencement of physical involution. It, therefore, becomes 
necessary for us to enquire in what those changes consist. 

One of the more important, indeed, perhaps the most 
important of all, because the others arise indirectly from it, 
is the diminution of nerve energy in the system. Nearly 
or quite all persons pass through a period at some time 
between the ages of forty-five and sixty-five during which 
they are sensible of a decided change in their feelings, 
as well as in their bodily health. The condition is one 
attended not so much with indications of actual disease, 
though it may be so, as it is with a feeling of weariness, 
indifference, or malaise. Persons do not experience the 
same pleasure in the business pursuits of life which they 
formerly had. They are unable to endure physical or 
mental exertion as well as formerly ; business cares annoy 
more easily, and change or periods of rest are more often 
required if they are able to have them, and especially 
desired whether they can have them or not. The appetite 



324 LECTURES ON MENTAL DISEASES. 

is not so keen, and food is not relished as before, and 
in consequence some diminution of weight in the body- 
occurs ; there is less strength and fullness of pulse, and 
the blood passes to the brain with less force, which doubt- 
less accounts for the diminution of good feelings and a 
slight tendency to look upon the dark side, if there exists 
any such to look upon. The period during which an 
increase of either physical or mental activity takes place 
has long since passed, and now the period during which 
it has held its own and exercised its largest capacity in the 
sphere of its activity has also passed. It has arrived upon 
the border- land of descent, and can no longer pass through 
the same amount of exertion ; or if it does, more marked 
and longer continued periods of exhaustion supervene, 
while a reaction comes more slowly. These and similar 
experiences occur to most persons between the ages ol 
forty-five and sixty-five, especially those who have been 
engaged in such occupations and avocations as require an 
excessive expenditure of nerve energy. Not unfrequently 
these abnormal experiences and changes in the system 
pass over into something of more grave import, and the 
individual may have an attack of physical disease, a 
pneumonia, a fever, an attack of rheumatism, or a disease 
of the kidneys, some of the more general effects of which 
may remain for a long time after the more acute symptoms 
have passed away. 

In the female, in addition to these changes in sensations 
and capacity for physical effort, the catamenia cease, and 
the tendencies as well as the capacity of the system to 
reproduce itself by conception and gestation and to nour- 
ish its offspring, which has for thirty or thirty- five years 
exercised so profound an influence, also ceases. The 
expenditure of nerve energy which hitherto has been 



CLIMACTERIC INSANITY. 325 

necessary for these physiological processes is no longer so, 
and must therefore cease, or be directed into other 
channels. These great physiological functions have their 
representative areas of cerebral tissue, and a corresponding 
change must occur in these- also. The evolution and 
manifestation of the thought, solicitude, and motherly 
anxiety which has been present during so long a period, 
and exercised so profound an influence in the care of help- 
less infancy and childhood, no longer find occasions for 
existence, and must seek other objects or persons on which 
to expend themselves. 

The elimination from the system of the products of 
secondary metamorphosis, which has hitherto taken place 
through the uterus, must hereafter occur through other 
organs and tissues of the body. The large supplies of 
blood which have in some degree passed through the 
pelvic organs at all times, and at the monthly period in a 
largely increased amount, must now find new or enlarged 
channels of circulation, until a less quantity is formed in 
the system. Hence, in nearly all females we find that 
sensations of " pressure and fullness " about the brain, 
which are frequently attended with abnormal sounds, and 
more or less of discomfort or positive suffering, are often 
complained of. 

In consequence of these important physiological changes 
in the working economy of the female system, the climac- 
teric becomes a more important epoch in the female than 
in the male, and more often leads to derangement of the 
physical and mental health. But it is essential to bear in 
mind that these physiological changes in the sexual 
system of the female do not stand in the relation of a 
single cause to such subsequent mental disease as may 
arise, unless in exceptional cases. They merely enter into 



326 - LECTURES ON MENTAL DISEASES. 

and form a portion of the aggregate of all the changes in 
the system which occur at this period of life. Menstrua- 
tion is almost always disturbed during an attack of mania 
or melancholia, at any period of life, and its normal 
appearance is one of the indications of a return to mental 
health, without reference to the age of the patient. Its 
disappearance in the large majority of cases stands in the 
relation of an effect and not of a cause. For both sexes, 
however, the climacteric must be regarded as a kind of 
halting place for the readjustment of the machinery of the 
different organs of the system to a modified course of 
functional activities, and in consequence of a diminution of 
nervous energy in conjunction with the initiation of a 
revolution of physical functions, according to inherent 
tendencies. 

The period during which many of the exciting causes of 
insanity which are potent at an early age are operative has 
now passed. This, however, is not the case as to the 
abuse of alcohol. Indeed, the physiological effects ol 
this upon the brain, when it has been long used, are more 
likely to exhibit themselves at this period, when the system 
has become less able to ward them off. 

Heredity — as in insanity occurring at the other great 
epochs of life — exercises a marked influence, and largely 
determines the degree of physical and mental disturbance 
which will exist in every individual case. 

The grand climacteric usually occurs in females between 
the ages of forty and fifty-five, and in males between fifty 
and sixty-five- The time varies considerably in different 
individuals, according to race, inheritance, and the habits 
and experiences of previous life. 

Symptoms. — The general tendencies of the physiological 
activities of the system as above described are in one direc- 



CLIMACTERIC INSANITY. 327 

tion, and we are, therefore, prepared to expect a condition 
of gloom and depression which leads on finally into one of 
melancholia. The leading symptom is melancholia with 
many of the attendant conditions which are present in that 
form of disease at other periods, and is attended by delusions 
of impending injury or ruin. The patient loses confidence 
in his ability to discharge the duties to which he has long 
been accustomed ; his interest in them has ceased, and the 
necessity of such employment is repugnant ; he soon be- 
comes unable to exercise his ordinary judgment in con- 
sequence of the distorted medium through which his 
perceptions are received ; he becomes irritable, impatient of 
opposition ; has suspicions of his business associates, and 
even the members of his own family ; is restless, desiring 
frequent change, or in some cases the opposite, preferring 
to be at home and alone. He exhibits little or none of the 
energy and activity which has formerly characterized his 
habits of life. Thought becomes introspective, and he is 
constantly accusing himself of having neglected to do his 
duty in some particular direction, more often religious-wise, 
if he has professed to be a religious person. The following 
case will illustrate some of these symptoms. 

Case i. — C. F. H., aged sixty-two, has a father living, 
and his mother was insane during many years. Habits 
ot life have always been regular, and he has conducted 
large business enterprises successfully during the past 
thirty years. He has a dark, sallow complexion, and looks 
thin and anxious. "His mother died insane, and one of his 
uncles was once in an asylum. He has been for months 
slowly running down and becoming more nervous and 
irritable, and at times emotional ; has often shed tears- 
Within a short time he has become greatly depressed ; 
thinks his character is ruined and that he is lost; that he 



328 LECTURES ON MENTAL DISEASES. 

has been a hypocrite ; that he has never lived up to his 
religious professions. Though he can talk connectedly and 
reasonably, and still retains sufficient inhibitory power to 
keep quiet for a few minutes, yet he is very sure that he 
will not be able to do so long, and that we shall soon be 
obliged to put him among those unable to conduct with 
propriety. He can talk about very little except himself, 
and if an attempt is made to converse on other topics, such 
as business or politics, in which he has always been inter- 
ested, after a few remarks he turns back to his own 
wretched condition and will not talk of anything else. He 
takes about one-half or two-thirds the usual amount of 
food, but insists that he has no appetite and that it does him 
no good. He complains of an unpleasant sensation about 
the region of the stomach, which does not amount to 
actual pain, but is expressed more nearly by saying it is 
an abnormal sensation or absence of feeling. He does 
not sleep well at any time, but always wakes after two or 
three hours, from the occurrence of some very disagreeable 
dream. He then walks about his room or remains awake 
until he takes a dose of medicine for the purpose of produc- 
ing sleep. He feels worse in the morning and is less able to 
control himself enough to go to the table or to converse long 
with any one than he is later in the day. Not long since, one 
morning, he handed me his watch and the money he had in 
his pocket, saying he could not take care of them ; but in the 
afternoon he felt so much better that he asked for them again. 
He has lost from twenty to thirty pounds of flesh ; his face 
looks pinched and haggard, especially in the morning ; the 
mucous surface of the mouth tends to dryness ; the delicacy 
of taste is impaired and he claims that one article of food 
tastes about as well as another ; the bowels are costive, not 
moving oftener than once in three or four days ; the food 



CLIMACTERIC INSANITY. 329 

is not well assimilated ; the skin darker than normal and 
dry ; the action of the heart is both feebler and slower and 
his general activities are much diminished. He requires to 
be urged to either walk or ride, except as he walks back- 
ward and forward in his room, during the mornings, bewail- 
ing some fancied neglect or sin of former days. The 
tendency of all thought is subjective, and he has the 
peculiarity which is frequently present in this variety of 
insanity, of complaining of an abnormal sensation about 
the bowels and stomach. He has so much distrust of him- 
self and of his ability to protect his own interests that he 
is constantly expressing anxiety lest I will not permit him 
to remain at the Retreat. 

This case terminated in a good recovery. After a resi- 
dence of nearly one year under care, and the free use of 
hypophosphates and opium, and food taken several times a 
day, he so far recovered as to be able to return to his own 
home, where he has remained most of the time, slowly 
improving mentally and gaining in good feeling, flesh, and 
strength. Several years have now passed and he remains 
in excellent health. 

It is generally the case in this form of insanity that 
persons present a simple state of melancholia; they have 
but little confidence in their ability to take care of them- 
selves, and are willing, and in many cases desirous, to be 
taken care of, and even to enter an asylum. The zest and 
relish of life is gone. If they have suicidal impulses they 
generally speak of them, and desire to be protected from 
carrying them into execution, though not always. 

A gentleman aged fifty-nine, of neurotic temperament, 
anaemic and thin in flesh, recently called to see me in refer- 
ence to his condition, and after stating his mental suffer- 
ings, anxieties, and fears lest he had been a hypocrite all 



330 LECTURES ON MENTAL DISEASES. 

his life, said that he was often overwhelmed by finding him- 
self meditating suicide, and his fear was that he should, 
during some one of his periods of sleeplessness and despair, 
so far lose consciousness as to do the deed. Suicidal im- 
pulses in this form of insanity are, however, less frequently 
carried into execution than in insanity at other periods of 
life, though attempts are sometimes made. 

Case 2. — A male aged fifty-eight, of great energy and 
force of character ; for more than twenty years has been 
engaged in large business enterprises in different parts of 
the country, which required much travel by rail, and which 
of late gave him great anxiety, thus tasking both physical 
and mental endurance. He has an inheritance of insanity 
from his mother, and his friends have observed a gradual 
failure in his physical and mental activities for several months 
before he finally quit his business and shut himself up in 
his own house, refusing to see any one except his wife. 
He was finally brought to the Retreat, in consequence of 
repeated threats of suicide, where he remained nearly four 
years before becoming well enough to be willing to go 
home. In addition to many of the general mental and 
physical conditions described as pertaining to the last case 
mentioned, he has been suicidal some of the time, in an 
extreme degree. On one occasion while walking on the 
street with his attendant and passing a meat market, he 
suddenly darted into the building, and seizing a cleaver, 
attempted to kill himself. At another time he ran from 
his attendant and attempted to throw himself into the river, 
but was overtaken before he could do so. A portion ol 
the time he has appeared to be in a condition of abject 
terror, and would remain in bed, if permitted to do so, day 
and night, with the bedclothes over his head, refusing to 
see any one ; he refused to take food and did not do so, 



CLIMACTERIC INSANITY. 33 I 

except on compulsion, during several weeks at a time. 
Peripheral sensations and groups of sensations became 
obscure to such an extent, during several months, that he 
never referred to them, and entirely neglected his person ; 
but, on the other hand, the visceral sensations became 
greatly exaggerated, and he was frequently referring to 
uneasy feelings in the region of stomach and duodenum ; 
he protested that his food did him no good, and that it 
was worse than useless to take it ; at other times he 
thought it was poisoned. 

Convalescence in this case was very slow. It became 
established after about two years, but his distrust of him- 
self and doubt as to his recovery continued for a year 
longer. It was with much difficulty that I could induce 
him to go with his attendant for short excursions into the 
neighboring country, and later to some of the towns to 
remain over night ; but he did so from time to time, and 
by degrees his distrust became less and confidence greater. 
His relish for food returned ; the uneasy sensations about 
the stomach disappeared ; the dominant idea of apprehen- 
sion which had so long ruled faded away ; the peripheral 
sensations became normal ; the secretions more active, and 
he was induced to return to his home, though much 
against his own inclination. There was no relapse, but, on 
the contrary, a continual improvement, until after five years 
from the first indications of the disease he became interested 
in his business, and though he has never resumed the full 
responsibility he formerly had, he is daily engaged in it, 
and is as cheerful and happy as during any former period 
of his life. 

In other forms of insanity, even when there exists much 
depression, patients are not only unwilling to leave home, 
but very confident that there is no need of their doing so ; 



332 LECTURES ON MENTAL DISEASES. 

while patients suffering from this form freely assent to 
be taken anywhere, they distrust themselves, and at the 
same time generally have such an appreciation of their 
condition, and such apprehension as to greater impending 
evil soon to overtake them, that they prefer to be placed 
under the care of others. 

Delusions of a more or less permanent character are 
present in a considerable per cent, of cases. They gener- 
ally refer to the individual himself, and take the form of 
some impending catastrophe, which is soon to overtake 
him ; patients believe that they have committed the unpar- 
donable sin, and in consequence will no longer indulge a 
hope of future life. They accuse themselves of duties 
neglected, of crimes committed, of which there has never 
existed the slightest evidence. These delusions doubtless 
arise from disturbances of the sensorial centres, and become 
pronounced from the constant introspective character of 
the thought process. They often exercise so profound an 
impression on the mind as to prevent sleep or to disturb 
it by horrid dreams. 

Patients frequently have the delusion that the food they 
use is poisoned and does not digest, or that it remains in 
the stomach or bowels as a source of irritation, and that 
it is consequently worse than useless to take it. Hallucin- 
ations of hearing are more frequent than those of the 
other senses, and the patient hears voices of condemnation 
assigning him or her to endless punishment or the fires of 
hell. Hallucinations of the other senses are less frequent 
than in melancholia at other periods of life. 

In connection with the above change in the mental func- 
tions, there occur others of the physical system. The 
patient loses flesh ; the appetite becomes less ; the relish 
for food falls off; and the mucous surfaces become less 



CLIMACTERIC INSANITY. 333 

moist, when food is taken, or, if it is not taken, the patient 
complains of uneasy sensations about the stomach and 
bowels, sensations which are not actually painful, but not 
normal, and which seem to be on the border-land of pain. 
The bowels are costive, and do not move except from the 
effects of medicine, and the secretions in general are defi- 
cient ; the skin becomes dry and harsh ; the face is pinched 
and wears a haggard expression ; the motor centres become 
excited at times, and the patient seeks relief in change ot 
position or in walking about his room. 

Case 3. — A woman, aged fifty-five, had ceased menstru- 
ation some four or five years ago, and had been the larger 
portion of her life in excellent health. There is no known 
heredity of insanity or other neurosis ; is the mother of four 
children, one of whom is deformed. One of her daughters 
died nearly two years ago, after an illness of some years, of 
consumption, and during all this time she was under the 
immediate care of her mother. During several months the 
mother was with her night and day, and toward the end 
was much broken of her rest. After the end, a reaction in 
the shape of mental depression came on ; she could not be 
induced to visit friends, or even to leave the house. 

This is the story in many of these cases of climacteric 
insanity. The person has been subject to a protracted ex- 
perience of over-anxiety and physical or mental exertion 
just at that period of life when the system is on the border 
land of decline, and requires, as never before, all its re- 
sources to sustain itself. Necessity, or the force of family 
ties, or pride in sustaining a business reputation, lend an 
inspiration toward the highest efforts the system can make 
for the accomplishment of what has appeared to be so im- 
portant and necessary at the time. At other periods of life 
rest and change would have restored the system, but at 



334 LECTURES ON MENTAL DISEASES. 

this time there is not enough of vital activity and nervous 
energy to do this until after months, and in some cases 
years, of comparative inaction. 

This patient became depressed, and was continually 
blaming and accusing herself of having been derelict of 
duty; she had the delusion that she was an incumbrance 
to her husband and unworthy of her children and many 
friends ; she had also exhibited such suicidal tendencies 
that she was not permitted to sleep in a room alone. At 
times since her admission she will make an effort to busy 
herself about some light work when urged to do so ; while 
at other times she remains for days unable to concentrate 
her mind upon any occupation, but still able to be about 
the hall and careful as to dress and personal appearance. 
She has lost flesh ; the skin is dry, the bowels costive, and 
all secretions scanty. She has the same uneasy sensations 
about the stomach and dislike of food that many patients of 
this class experience. She says very little, and it is not easy 
to ascertain how much she is influenced by dominant ideas, 
but we have no reason to suppose that she has hallucina- 
tions. She remains during the day, at times several weeks 
in succession, in a chair or on the lounge, repeating in a 
low tone of voice a wish that God would " kill her," and 
has never given indications of improvement longer than a 
few days at a time. 

Case 4. — I here introduce another case as illustrating 
the prodromatous stage of this form of disease — a condition 
which frequently does not pass into one of insanity, and 
during the continuance of which patients do not usually 
reach insane asylums. 

E. V., a person who has been engaged in very large 
business enterprises, and has also been very successful in 
them, came to consult me in 1885. He said he had not 



CLIMACTERIC INSANITY. 335 

had a good night's sleep for many months, had abandoned 
business, and left home ; was staying in the country where 
he could take exercise by walking, and where he would be 
sure not to meet his business friends or any of his relations 
except his wife, who was with him. Though worth several 
hundred thousand dollars and formerly very liberal and 
public spirited, he now felt that he was poor and in the 
way to rapidly become more so ; indeed, he could now 
scarcely afford to pay the physician's fee. He shrunk from 
seeing his old business acquaintances and from all re- 
sponsibility ; could not sleep except at intervals during the 
night, and when. awake was mentally engaged in going 
over his past mistakes. After one of these awakenings, 
almost the first thought would be in connection with some 
one of these mistakes on which he had before reflected, 
and it affected him with a mental shock which he felt radi- 
ated from the brain to the region of the heart, causing 
actual pain there for a considerable period. This dominant 
idea then would hold rule in his course of thought during 
what seemed to him a long time, and he could not change 
it until the brain became partially exhausted, and then it 
gradually became more indistinct, and he would again sleep. 
When he again awoke, an idea in relation to another subject 
would flash into existence, and its influence radiate pain- 
fully to all parts of his system ; he would then pass 
through another similar experience. These occurrences 
rendered his nights very tedious and dreadful ; they were 
repeated every night for several months, and he fully 
realized their morbid character. He had lost appetite and 
flesh, and was dreading the occurrence of some pronounced 
physical illness. His energy and courage were gone, and 
with them his ability to face the realities of life. 



33^ LECTURES ON MENTAL DISEASES. 

The use of opium, strychnia, and phosphorus, several 
months of travel, with the incidental changes of scene, 
and association with persons with whom he had never 
before had any personal or business relations, greatly 
changed his physical and mental health, and he became 
able to see and enjoy the society of former friends and the 
duties pertaining to a business life. 

The above case is one of a class which will come under 
the professional observation of general practitioners of 
medicine and call for treatment more frequently than those 
patients who have passed over into a more pronounced 
mental disturbance. Many of them will recover without 
much medicine, simply by the experience of a thorough 
change and a relief from the routine of business life to 
which they have been long subjected. This can be effected 
more fully by travel, visits to new scenes, and residence of 
a few months in a climate unlike the one to which they 
have been accustomed. Such a change brings them into 
new associations, and inevitably tends to lead the course of 
mental activities into different channels. 

In reviewing the symptoms and general conditions per- 
taining to the above cases, we are at once struck with the 
resemblance they sustain to those which usually exist in 
melancholia when occurring at other periods of life. Many 
writers have described them under the general term of 
melancholia, and yet, on a more careful clinical study, I 
think there will be found good reason for classing them as 
pertaining to a special variety of insanity. It is true that 
there are mental and physical symptoms, some of which 
exist in other varieties, and this is equally true in other 
insanities, such as general paralysis, alcoholic and senile 
insanity, and yet, as in other special forms of disease, there 



CLIMACTERIC INSANITY. 337 

are found certain conditions more or less peculiar to them, 
so in this there appears to be enough which is peculiar to 
it to warrant its assignment to a special genus. 

In the first place, it develops from and is the result of 
changes in the physiological activities of the system which 
occur at the climacteric and which do not occur at earlier 
periods, and the general symptoms are determined by these 
changes. In ordinary melancholia, whatever changes 
occur in the general physical system are mainly subsequent 
to and proceed from the condition of the brain. 

In climacteric insanity the physical changes of the whole 
system, and especially the sexual, are the direct cause of 
the mental conditions, while in ordinary melancholia the 
physical conditions generally proceed from and are caused 
by it. 

Again, in climacteric insanity the patient more gener- 
ally realizes the failure of his physical system, and is only 
too deeply impressed by the fact that his nervous energy 
has left him. His condition is one of weakness and failure; 
from which he forecasts greater physical debility and other 
evils in the future ; whereas in the ordinary variety of 
melancholia all of the disorder is referred to the brain, and 
little is said or realized in reference to bodily changes and 
conditions. 

Again, in this variety, there very often exists a super- 
sensitive condition of that portion of the brain at or near 
the origin of the pneumogastric nerve, and impressions 
received are often radiated to the epigastric region, and also 
to the heart, with such force as to be realized by the patient 
and cause much discomfort. Dominant ideas arising from 
these impressions, such as that food does no good, that it 
remains in the stomach or bowels as a source of irritation, 
that it is poison, etc. etc., are more common than in simple 
29 



338 LECTURES ON MENTAL DISEASES. 

melancholia ; and when food is refused it is rather in conse- 
quence of such dominant impressions, than because there 
is no appetite, or that it is not wanted. The feeling of 
depression is so fully realized as often to lead the patient 
to desire to be under the protection of an institution 
rather than with his own family, and when convalescing, 
and so far on the road to health as to be able to return 
home, there is little interest in the society of wife or 
family. The sexual instinct, which has during so many 
years exercised so profound an influence in determining 
the course of activities, is now nil ; and not unfrequently 
the other sex is shunned or treated with entire indifference. 

The relative proportion of cases occurring in the two 
sexes, in the Retreat during the last fifteen years, is of 
females to males about as 2 to 1; or, more accurately, as 57 
to 26. 

Prognosis. — The statistics of the Retreat during the last 
fifteen years indicate that recoveries from attacks of acute 
climacteric insanity are as frequent as from other forms of 
disease. More than sixty per cent of such cases have made 
recoveries. This is a little higher per cent, of recoveries 
than appears in the experience of either Dr. Clouston, Dr. 
Merson, or Dr. Lewis. The recovery rate of these authors 
are respectively 57, 59.5, and 48 per cent. It is, however, 
doubtless true that the patients coming under treatment in 
the Retreat have been of a class in which, from the charac- 
ter of former experiences, there would exist a larger prob- 
ability of recovery than would be true of persons in the 
humbler walks of life. Very few of the cases have had an 
experience in the abuse of alcohol or of great physical 
labor and of unfavorable climatic conditions, few have had 
physical injuries of any kind, and, therefore, the system 
was in a more favorable condition for recovery than would 



CLIMACTERIC INSANITY. 339 

have existed in persons whose lives have been passed in 
physical labor and the incident exposures. The heredity 
of the patient as to longevity and physical health will also 
prove an important factor in the prognosis. 

Recoveries in even the mildest cases of climacteric 
insanity rarely occur sooner than three months, and the 
large majority continue between one or two years. The 
fact that the patient has passed one year or even two with- 
out recovery should not lead to an unfavorable prognosis, 
unless there exist indications of physical disease of a serious 
character. The length of time during which the physio- 
logical changes incident to this period, and which are then 
proximate causes of the disorder, may take place will vary 
much according to inheritance and past experiences, and 
unless there should occur some form of physical disease to 
complicate the expectancy, we may anticipate a recovery 
in some patients even after two years. 

The question may be asked, do such patients remain in 
good mental health, or does there exist a greater danger of 
another attack than exists after recovery from other forms 
of insanity? The experience at the Retreat indicates a 
negative reply to the latter question. It should, however, 
be said that this expectancy will depend largely upon the 
antecedents of the patient. If the habits of life have been 
regular, and the patient has not been addicted to excesses 
of any kind, and is free from physical disease, and especially 
if there exists a capital of mental resources, with which to 
engage in occupations congenial to the former mode of life, 
together with those anticipations which arise in connection 
with family, children, and property, we may with reason 
anticipate a period of several years of mental health. The 
younger the patient, other conditions being the same, the 
greater the probability of a recovery. When the system 



34-0 LECTURES ON MENTAL DISEASES. 

has passed fifty-five or sixty years of age, there exists a 
rapidly diminishing capacity for overcoming the conditions 
of disease, especially if the experiences of past life have 
been of an unfavorable character or the patient has in- 
dulged in the abuse of alcohol in any of its forms. 

Treatment in a large number of these cases must be 
of a stimulant and tonic character; a large amount of time 
spent in the open air ; gentle exercise ; an abundance ot 
nourishing food in the form of soups, beef-tea, eggs, and 
milk (in some cases with brandy) ; patients should never be 
allowed to go long without food, and if necessary it must be 
administered ; opium, cod-liver oil, iron, strychnia, quinine, 
and phosphorus. In my experience opium is remarkably 
well borne in this form of insanity, and is certainly of great 
value in alleviating the suffering and diminishing mental 
activity. It should be used in the form suggested when 
recommending it in melancholia. It should be given in 
doses of from twenty to sixty minims three times a day. 
I have never known the opium habit to become established 
from its use after this method and for this purpose, even 
during several weeks, and as the patient becomes stronger, 
it can be gradually reduced in quantity until it is entirely 
omitted with little or no inconvenience. Its use is some- 
times followed by the most favorable results, though I am 
unable to predict beforehand in what cases it would be 
likely to do so. Sleep may be secured by exercise in the 
open air, and, if necessary, the use of sulfonal, chloralamid 
or chloral, combined with the bromide of sodium or ammo- 
nium. 



LECTURE XVIII. 



INSANITY OF THE PUERPERAL PERIOD. 

i. Insanity of Pregnancy. 

Importance of — Insanity of Pregnancy — Etiology — Intimate Relation between 
the Brain, the Stomach, and Sexual Organs — Craving for Particular Arti- 
cles of Food while in the Pregnant State — Heredity — Tables of Cases 
in the Connecticut Hospital and the Retreat —First Pregnancies — Symp- 
toms — Puerperal Insanity Proper — More Frequent in First Labors 
between Thirty and Forty Years of Age — Frequency of in Scotland — 
Character of Blood in Puerperal Insanity — Symptoms, Primary and 
Secondary — Hallucinations — Homicidal and Suicidal Tendencies — Con- 
valescence — Age — Table of Thirty-nine Cases in Reference to Recoveries, 
Ages, and Time under Treatment — Cases. 

The general practitioner has professional care of women 
during periods of pregnancy, childbirth, and lactation. He 
assumes the responsibility of ministering to the discomforts 
which are incident to the first period, the perils that attend 
the second, and such derangements of the system as may 
arise during the third. It may not be too much to claim that, 
while in the majority of women these periods pass without 
serious results to either mother or child, yet certainly two 
of them are attended by such conditions of discomfort and 
suffering, with many mothers, as to render the care and 
skill of the physician even more acceptable than do many 
other ailments for which he is called to prescribe. But no 
one of these many disordered conditions, whether surgical 
or medical, is more serious and important than that of 

341 



342 LECTURES ON MENTAL DISEASES. 

insanity. In most cases its advent is unlooked for; in 
many its symptoms appear unannounced beforehand, and 
suddenly in the majority of cases. They are acute, posi- 
tive, and unmistakable, and move forward in the develop- 
ment of their character so rapidly as to arouse the most 
apathetic husband, brother, or sister into intense anxiety 
and alarm. 

The prodromous stage of most other forms of insanity is 
more prolonged. The symptoms develop slowly. The 
relations and friends are slow to perceive the initial and 
early changes in the mental states, and generally still more 
so to acknowledge them when suspected. The physician, 
therefore, is not early consulted and rarely sees his patient 
until weeks or months have passed and he is far on in the per- 
ilous journey. Not so in the puerperal case ; time is rarely 
lost by delay, and his resources, both medical and moral, 
receive a loud and early summons. The general practi- 
tioner, therefore, comes into more intimate relations to the 
early period of puerperal insanity than with that of any 
other, and in consequence is regarded by his friends as 
having a larger measure of responsibility. 

While the term puerperal is applied to the state incident 
to parturition, yet as this latter is necessarily connected 
with and presupposes both gestation and subsequent lac- 
tation, it will be for our advantage to study together the 
mental disorders which may exist in connection with the 
three periods. While the symptoms of these periods tend 
to merge gradually into each other, and it is doubtless true 
that no "sharply defined line can be drawn between them, 
yet they have some differences in both character and aeti- 
ology which it is worth while to observe. 



INSANITY OF PREGNANCY. 343 



INSANITY OF PREGNANCY. 

Etiology. — Physicians are often reminded by professional 
experiences of the intimate sympathy which exists between 
the brain and the viscera and of their interdependence in 
the discharge of their ordinary functions. One of the most 
common examples of this sympathy relates to the stomach. 
Continued acute pain in either the brain or the stomach 
very soon modifies the functional activity of the other 
organ. This intimate sympathy, however, exists between 
the different viscera themselves, and the physician is often 
called to give counsel and, so far as he may be able, relief 
to pregnant women suffering from this cause. Nausea 
when arising from simple and direct causes produces a 
most profoundly depressing effect, and this is much in- 
creased when it arises from the irritation of a growing 
pregnant uterus and from the changed currents of blood 
which it requires in consequence of its increase of volume. 
And when these functional changes are in operation not 
only for a few hours, but during days and weeks, it is 
readily perceived how great the depression may become in 
some sensitively organized women. 

There are, however, many women who, though not seri- 
ously affected with nausea and vomiting, yet, as the gravid 
uterus becomes larger from month to month, and begins to 
rise out of the pelvis, affecting the neighboring organs, 
suffer much mentally from these reflex influences. Accord- 
ing to the observation of Dr. Savage more mental disturb- 
ance is likely to occur when the offspring is male than 
when it is female ; and he says that this coincides with the 
popular idea on this matter. Many women rarely or never 
feel in their normal condition, and often have a craving for 
some particular article of diet, and unless they can have it 



344 LECTURES ON MENTAL DISEASES. 

the general impression, which has no foundation in either 
reason or fact, is that there will result some unfavorable 
effect upon the child in utero. This craving appears to be 
similar to that of the dipsomaniac at times, and becomes 
about as uncontrollable. It is certainly impossible to sat- 
isfy its extraordinary demands. 

In other cases the nerve centres become somewhat 
irritable and sensitive, doubtless from these same changed 
currents of blood supply, and the subjects are fretful and 
unable to view their surroundings and experiences in a 
hopeful way. They are depressed and spend hours in 
anticipating some form of trouble which will arise at the 
time of the coming confinement, or before then. The 
experience is altogether unknown, and in the depressed 
state of the nervous system the mind conjures up and 
pictures all forms of danger as the time for confinement 
approaches. 

The sexual antipathy toward the husband which not 
unfrequently exists during pregnancy in many women may 
lead them to imagine that their husbands do not love and 
sympathize with them as they should. Some careless word 
or sentence spoken in merriment may be interpreted as an 
evidence that their friends do not longer care for them, 
especially if they have failed to visit them as often as for- 
merly. They are confident that other women have never 
suffered as they are doing, and experience many imperfectly 
defined apprehensions of impending danger. These abnor- 
mal changes may become so great as to implicate the judg- 
ment and cause most remarkable likes and dislikes and 
violent caprices. They especially dislike their husbands 
and will have little or nothing to do with them, and can 
rarely speak civilly to them. I was invited to visit such a 
case several years since. The woman had actually left her 



INSANITY OF PREGNANCY. 345 

husband and gone to her mother, declaring that she would 
no longer live with him, though she exhibited no other 
definite indications of insanity. 

This and much more of a similar character, indicating 
how greatly the emotional system is often affected from 
the influence of a gravid uterus, may occur with females 
during their first and sometimes in succeeding pregnancies, 
and yet the mind not become so much affected that the 
subject is regarded as wholly irresponsible. Indeed, we 
must bear in mind the fact that no such experiences ought 
to result from the conditions of pregnancy ; that the prime 
physiological purpose of the uterus is that of child-bearing; 
and that if women had never lived in the conditions of 
civilization, or disregarded the laws of their physical nature, 
there would occur no greater irritation from the pregnant 
state than is the case with the females of other animals. 

These disturbances of the emotional system during the 
period of pregnancy, however, are of special importance in 
two respects. In the first place, when existing in an exag- 
gerated degree, they may be regarded as harbingers, or 
rather as danger signals, which may warn the physician of 
the coming of more serious ones, either during the later 
period of pregnancy or during the periods which are sub- 
sea x uent to confinement. They may almost insensibly 
merge into the morbid mental states incidental to the 
puerperal or lactational periods, especially the latter. In 
the second place, they present states of mind which are on 
the border line, if any such exists, between sanity and in- 
sanity. They indicate, as almost no others do, how imper- 
ceptibly the one state merges into the other, and also how 
quickly the one state may change for the other. The 
morbid mental state of to-day may be changed for one of 
comparative composure and " sweet reasonableness " to- 
30 



346 LECTURES ON MENTAL DISEASES. 

morrow. The depression or emotional excitement of the 
morning may give place to hopeful expectation in the 
evening. 

In those cases of pregnancy, therefore, in which the 
nerve centres become so profoundly affected that insanity 
results, it becomes necessary to introduce another element 
of aetiology, *.*., that of heredity, or a predisposition. 
When the nervous system is so burdened, or is very sensi- 
tively or delicately poised, the irritation arising from such 
physiological processes may then prove sufficient to cause 
serious derangement of the mind. When such is the case 
the disorder generally assumes the form of melancholia. 
The table on opposite page, which includes the cases of 
the insanity of pregnancy that have been admitted to 
the Retreat since 1845, indicates how influential is the 
factor of predisposition both in the history and ter- 
mination. 

Insanity is said to occur more often during the first 
pregnancy than in subsequent ones, and in females who 
either have not been married at all, or have married late in 
life. Its importance then is increased, as its effects relate 
to two lives instead of one, and are likely to arise in subse- 
quent pregnancies or parturitions. Such cases are of 
special importance to general practitioners, as friends hesi- 
tate to place them in institutions ; and, indeed, very few 
institutions have the requisite accommodations for their 
proper care. There can exist no doubt that many cases of 
insanity during pregnancy are cared for at home for this 
reason and because of the large measure of sympathy and 
anxiety which could not be aroused in other forms of the 
disorder. 



INSANITY OF PREGNANCY.— RETREAT. 



Age. 


No. OF 
Preg- 
nancy. 


Symptoms. ' Heredity. Result. 


Subsequent 
History. 


28 


1st. 


Melancholia. Not stated. 
Agitans. 


Stationary. 


None. 


26 


1st. 


Melancholia. Father in- 
Anaemia. sane. 


Recovered. 


None. 


32 


1st. 


Melancholia. Mother in- 
Ill-health. sane. 
Vomiting. 


Stationary. 


Removed when 
found to be 
pregnant. 


41 


3d- 


Melancholia. 


Not stated. 


Improved. 


Had had several 
other puerpe- 
ral attacks. 


44 


3^ 


Depressed. 


Mother in- 
sane. 


Recovered. 


Had one previ- 
ous attack. 

Suppressed 
menses excit- 
ing cause. 


31 


1st. 


Melancholia. 


Father in- 
sane. 


Recovered. 


Had had one mis 
carriage. Ill 
health. 


33 


4th. 


Melancholia. 


Not stated. 


Improved. 


Admitted twice 
subsequently. 
Had prolapsus 
uteri. 


22 


ISt. 


Melancholia. 


Mother and 
sister had 
had puer- 
peral in- 
sanity. 


Stationary. 


No subsequent 
history. 


28 


4th. 


Mania. j Not stated. 


Improved. 


No subsequent 
history. 


36 


8th. 


Mania. 
Delusions. 


Not stated. 


Recovered in 
three and 
one - half 
months, in 
sixth month 
of preg- 
nancy. 


No subsequent 
history. 


34 4th. 


Melancholia. 


Not stated. 


Stationary, 
after four 
mo n t h s' 
treatment. 





347 



348 



LECTURES ON MENTAL DISEASES. 



CASES OF INSANITY OF 
HOSPITAL 



PREGNANCY IN CONNECTICUT 
FOR INSANE * 



Age. 


No. OF 

Previous 

Attacks of 

Puerperal 

Insanity. 


Form of Disease. 


Result. 


Remarks. 


36 


I 


Melancholia. 
Delusions. 


Recovered in 6 
weeks. 




38 


1 


Mania. 
Delusions. 


Depressed. 


Miscarriage. 


35 


I 


Mania. 


Recovered in 2 
months. 


Mother insane. 


29 


3 


Mania. 


Recovered in 11 
months. 




22 


1 


Maniacal. 


Recovered in 6 
months. 


Had four subsequent 
attacks. 


26 


None. 


Maniacal. 
Homicidal. 


Improved in 12 
months. 


Readmitted after two 
years. 


28 


None. 


Melancholia. 
Suicidal. 


Stationary after 
3 months' treat- 
ment. 




46 


None. 


Mania. 


Died from acci- 
dent after 3 
years. 





Symptoms. — These are nearly always of a depressive 
character. They appear to develop from the primary 
states of emotional excitement, suspicion, and irritability, 
to which allusion has already been made. Persons not 
only become restless and irritable, but unable to control 
these states. They are sleepless, suspicious, and imagine 



* Furnished by Dr. James Olmsted, Superintendent, 



PUERPERAL INSANITY. 349 

that their husbands are visiting other women ; have suspi- 
cions that their food is poisoned and refuse to take it ; are 
careless of dress and personal appearance, and become 
apathetic. 

Dr. J. Batty Tuke says that " in no form of insanity is 
the suicidal tendency so well marked. Thirteen patients 
out of twenty-eight have either attempted or meditated 
suicide. In some the attempts were most determined — a 
loathing of life and the most intense desire to get rid of it 
being the actuating motives." At times the excitement and 
irritability become so great as to render them dangerous to 
those having the care of them ; this generally arises from 
some form of delusion or hallucination. 

In other cases there appears a depravity of the moral 
nature as exaggerated as that already described as arising 
in the physical appetites. Women who have always borne 
reputations of the highest character are overcome with a 
desire to appropriate articles belonging to others, of almost 
any kind, which they may chance to see. These may be of 
very little value and such as the person never before had 
any interest in possessing, but the desire to appropriate 
them now becomes quite irresistible, and little effort is made 
to conceal it from others. In short, they are veritable 
kleptomaniacs, and at times it may become a very delicate 
duty of the physician to give his opinion in such cases, and 
to explain how such methods of conduct may depend upon 
the mental derangement of pregnancy. 



PUERPERAL INSANITY. 

The term puerperal insanity will be used as descriptive 
of cases which may develop immediately after delivery and 
also of those which may arise during the first succeeding 



350 LECTURES ON MENTAL DISEASES. 

five or six weeks. Nearly all cases develop within a month 
and many within a few days. In 27 of 68 cases studied, 
the symptoms are reported to have appeared "immediately" 
after delivery and in 22 others within one week; in seven 
of the remainder the symptoms appeared during the second 
week; in five during, the third week, and in the remaining 
nine during the fourth week. 

It more frequently occurs in primipara, and the proba- 
bility of its recurrence becomes less in each subsequent 
labor, as the uterus and nervous system become accustomed 
to these physiological experiences. In 175 cases at the 
Retreat 125,01- 71 per cent., occurred in first labors, twenty- 
six in second labors, seven in third, three in fourth, two 
in fifth, one in sixth, while eleven have no record in this 
respect. 

According to some authors it is more frequent after the 
first labors of women who are between thirty and forty 
years of age, than in the first labors of younger women, 
especially if the labors are attended with injuries to the 
soft parts, or the delivery is effected by the use of instru- 
ments. This statement, so far as it relates to age, is not 
corroborated by the statistics of cases at the Retreat. The 
number of those under 20 years of age is three ; between 
20 and 30, 89 ; between 30 and 40, 66 ; 40 years and over, 
14; and in three the age is not stated. There exists, of 
course, a more or less strong probability of error in refer- 
ence to the factor of age as reported. 

When we take into consideration the large quantity of 
blood lost at the termination of many labors and the conse- 
quent change in the general circulation ; also the change 
which occurs in the quality of the blood by the sudden 
introduction of fluids which lower the relative quantity of 
its solid constituents, thus rendering it less fit for its normal 



PUERPERAL INSANITY. 35 I 

physiological function; the long hours of suffering and 
straining, with the incident pressure of blood upon the 
sensitive tissues comprising the cerebrum, and add to these 
the emotional disturbances which occur from calling into 
activity the maternal instincts and all that is embraced in 
these in the way of sudden and profound impulses and 
states which arise in many delicate women, — we surely may 
be surprised that more of them do not become insane dur- 
ing the puerperal period, especially when the element of 
heredity exists. According to Dr. Clouston, in Scotland, 
only one woman in 400 becomes insane from child-bearing. 
The statistics of the Retreat and the Connecticut Hospital 
for the Insane indicate a still smaller per cent, in Con- 
necticut. 

The deteriorated condition of the blood which exists in 
many women during the week next subsequent to labor, 
from the partial suppression of the lochial discharge, espe- 
cially when local lesions of the neck of the uterus, the 
vagina, or the external parts has occurred ; imperfect and 
unequal contractions of the uterus when continuing for 
several days after labor, the results of retention of portions 
of the membranes or placenta, — all are of more or less 
importance as elements in the aetiology of puerperal insan- 
ity. 

Dr. Bevan Lewis * furnishes the following table of five 
cases, indicating the character of the blood in puerperal 
insanity : — 

* " Text-Look of Mental Diseases," p. 370. 



35: 



LECTURES ON MENTAL DISEASES. 





OO •— 

(U CU 




CU 

a 


gg 


i) IT 
>- S 

.s 


CJ 


cu 






11 

CU 0) 

oo ^ 




G 
cu 


«o o 
o Z 


a. 
cu 

'el 


15 








"oo 

G 


i2 

T3 Vn 


^ ^ G 
,flj J2 G 

^3 u^ 


CJ 








~ OO 


<u 


o 

CJ 


g c 


q . 


s 


1 




c S 
03 cu 

.9 £ 
e.S 

is 

<L> C 
« G 


o 

oo 

3 

CU 
•h 

O 

o 

4) 

a 
>-. 


CL) 

O 

s 

©3 

rG 

3 

aT 


CU S 

s 22 

p 

cj a, 

JJ G 


O G g 

^? ^ G 

5 <u IS 
§ S S 

-3 cu 

g 2"! 


*j "3 
■3 1 

O *j 

5 .Si 

oo 

G-Q 


G 
G 

'cS 

1 




C/j 


«"• t/1 


>, 


T3 


«*-. C3 .« 


£ c* 


^ 




* 


■^ a 


G 


O 


<J j_, 


O " rt . 


»»^ 


.cu 




< 
S 


*1 


H3 


O 

3 


3 1= 


£ ooo 

O w : 




el 




<& 


5 o 
8lJ§ 
o.+j o 


G 
O 

.2 


oo 
CU 

o 

03 
<U 

3 


<U CJ 

'ao r d 

G 

.5 rt 
e v 

^— uo 

'-5 5^ 


o 3 o 

X O 
cl O « 

^ cu 3 

■ti oo 

— 3 08 

03 C cu 

i= - c S 
O G ~ 


s ... 

o 5i 
o "5- 


s 

cu OO 

3 ^ 






Cu e ^J 

x a £ 
« « o 

S o-d 


CU 

'So 


G 
cu 

"3 

G 

a 

03 

a 


Sjs 

s . s 

-O 41 « 
C •- CU 

g .22 ojo 


3 

oj 

cu c 

« c 


D- oo 
O cu 

° s 

CU uo 

.a cu 

OO 

s §. 






V- g § 


3 
G 


_ G 03 
T3 TD T3 
<u 


| §-.§ 


§-£ 


Is 


<u 

G 

o 




w 


i 


Cn 


p< 


u 


S 


55 


H t/) . 












i 


1 




< ° s J 
> c3 u 












i 


i 




vo 


00 


o 


VO 


ON 


vD 


u^ 


^h 


ro 


vq 


vq 


■* 


4 ~^ 


r^ 


t-« 


'T 


W UO u . 


















H 3 oi> S h 


i^> 


vo 


M 


vo 


00 


f<j 


'* 


oo 


N 


q 


i-i 




CN 


(N 


CN 




Red 

Corpus- 
cles, 
per 

H^MIC 

Unit 


vO 


■* 


oo 


MD 


vO 


oo 


vO 




ro 


M 


6 


m 


<-o 


<s 


6 


-*■ 


vn 


■* 


^t- 


t^ 


CD> 


o 


00 


CM 


o z ,• 

t; >- aj H 

S a 3 z 

* O £ M 


O 


00 


oo 


<N 


't 


00 


o 


u-> 


cn 


CM 


CM 


CO 


r-^ 


tx. 


VO 


lO 


x£ u 


































00 










t^ 


t^ 


t-^. 


*-* 


oc 


Cfl 


00 


00 


00 


OO 
00 


00 
00 


00 


OO 
00 


oo 


w 


oo 


00 


oo 








> 1 
1-1 oT 




< 


_" 


Tp 


oo" 


^o" 


i— to 


1-1 cn" 


> 6 




^_- 


jj 


jj 


> 


> 


> 


cj 


bio 




o 


cj 


o 


o 


o 


o 


cu 


G 




o 


O 


o 


fc 


» 


•z 


Q 


< 



PUERPERAL INSANITY. 353 

Symptoms. — When the disorder arises within a few 
days after childbirth the symptoms are nearly always of a 
maniacal type. The contrast in this respect with those 
which exist in the insanity of pregnancy is very marked. 
Of the 175 cases in the Retreat 135 were maniacal. Of 36 
cases in which the symptoms developed within four weeks 
22 were maniacal, 1 1 had symptoms of melancholia, and 3 
had alternating states of excitement and depression. 

In the primary stage the patient becomes talkative, 
changeable, unreasonable, restless, suspicious, and exhibits 
feelings of aversion toward her husband and other mem- 
bers of the family ; demands things which she has not been 
accustomed to have, and if refused may burst into tears and 
become much excited. The eyes become over- sensitive to 
the presence of light and present an unusually bright and 
excited appearance. The face begins to take on a haggard 
expression ; the skin becomes moist and the tongue dry- 
Tenderness on pressure over the uterus may or may not be 
present. And in some cases the bowels become distended 
and tympanitic. The patient refuses food, both solid and 
liquid, and declares that she hears voices which forbid her 
to take it ; and at times may be controlled by the delusion 
that the food is poisoned. 

In some cases one of the earliest indications of the ap- 
proach of disease consists in the exhibition of a morbid 
character of the maternal feeling toward the newborn child. 
The mother looks askance at it and desires that it be taken 
from the bed and out of the room, realizing in some meas- 
ure that she may do it injury if it is left with her. Horrible 
impulses come into consciousness which she fears she may 
be unable to control, and sometimes they end in terrible 
catastrophies before the friends realize the danger or fully 
appreciate the fact that disease exists. These unusual 



354 LECTURES ON MENTAL DISEASES. 

exhibitions of abnormal maternal instinct are sometimes 
thought little of by friends and may be attributed to 
irritability or willfulness. They, however, exist in so large 
a per cent, of cases that it should never be considered as 
safe to leave the child alone with the mother. 

These semi-acute symptoms may continue for a few days 
or may suddenly become intensified ; the patient becomes 
more talkative, excited, and violent; is unable to sleep and 
does not, except from the effects of large doses of medi- 
cine; indeed, insomnia is one of the most constant of 
symptoms. The aural and visual hallucinations become 
more distinct and dominating. Hallucinations of general 
sensation and of taste and smell are not common, nor are 
hallucinations usually present except in cases of mania. 

Twelve of 22 cases of puerperal mania experienced both 
aural and visual hallucinations ; while they were present in 
only 33 per cent, of 36 cases affected alternately with mania 
and melancholia. Hallucinations of sight are generally of 
an unpleasant or frightful character, and in this respect 
resemble those existing in delirium tremens. Some pa- 
tients have visions of impending evil and endeavor to throw 
themselves from the bed or out of the window to avoid the 
imaginary danger. They become noisy, extremely talka- 
tive, or incoherent ; obscene in looks, acts, and language ; 
expose their persons by suddenly throwing off the bed- 
clothes ; and exhibit great physical force for a short time 
during the periods of sudden violence which frequently 
occur. 

The pulse generally becomes increased in frequency 
during the first stage of the disorder, and soon gives evi- 
dence of diminishing strength. The nervous system 
becomes highly sensitive, so that the shutting of a door or 
other sudden sound causes the patient to start with fright, 



PUERPERAL INSANITY. 355 

the immediate effects of which do not pass off for a consid- 
erable time. 

Both homicidal and suicidal tendencies may exist. In 
the first case the patient is generally under the domi- 
nance of the delusion that the nurse or some member 
of the family who may have the care of her is about to do 
her injury, and she suddenly attacks the person in self- 
defense, using every means in her power to defend herself 
and destroy her imaginary enemy. Delusions are gener- 
ally present in from 33 to 50 per cent, of all cases and in a 
still larger per cent, of maniacal cases. They seem to arise 
from hallucinations, and as these are, as already noted, 
nearly always of a terrorizing character the delusions are 
those of impending danger and injury. Food is refused 
because it is poisoned and every one is conspiring to take 
her life. In the second case she makes an effort to fly from 
some impending evil which seems to come to her through 
the presence of hallucinations, and the intense fear appears 
to drive all other thoughts, except those of safety, from her 
mind. She screams with terror and tries to dash herselt 
against the w r alls of the room, to throw herself from the 
window, or strangle herself if left alone long enough to 
enable her to make the attempt. In the 175 cases at the 
Retreat suicidal impulse or efforts are noted in only 15 
per cent. Of 36 cases at the Connecticut Hospital for the 
Insane 33 per cent, were either homicidal or suicidal or both ; 
and 27 per cent, had made attempts to injure the offspring. 

These conditions of excitement usually continue ten 
days or two weeks and are succeeded by a more or less 
protracted period of dementia or melancholia, attended with 
delusions which often relate to the members of her family. 
Hallucinations are rarely present in the latter stages of the 
disorder. 



3^6 LECTURES ON MENTAL DISEASES. 

In those cases in which the symptoms assume the type 
of melancholia or dementia from the first, the physical 
symptoms described as pertaining to puerperal insanity are 
not present. In the larger proportion of such cases the 
development of the disease is postponed until after the fifth 
week or later. Hallucinations are much less frequent and 
if present less frightful in character. Delusions, if present, 
are of the same general character as those which are pres- 
ent in melancholia from other causes. The character ol 
thought is subjective; insomnia is often present and the 
patient is dominated with the belief that she is deserted by 
husband and friends, that she is unworthy, and is to be for- 
ever punished, etc. Ol 1 14 cases in the Connecticut Hospi- 
tal for the Insane 26 per cent, presented symptoms of 
melancholia. 

Convalescence generally becomes established in the 
course of eight or ten weeks. The force of delusions 
gradually fades away, the mind becomes more active and 
interested in the details of daily life, and also in the pres- 
ence of friends or relatives who may visit them, and from 
this period the patient passes on to a good recovery. In 
20 cases there was a recovery in 75 per cent., and in nearly 
all within a period of five months. In 39 cases of recovery 
at the Connecticut Hospital five occurred in less than four 
weeks, 15 in less than eight weeks, six in less than 12 
weeks and the remaining 13 in periods of from five to ten 
months. If the recovery is postponed beyond the period of 
five months the probability of its occurrence rapidly dimin- 
ishes. The prognosis will therefore depend considerably on 
the length of time which has elapsed since the onset of the 
disorder. According to Dr. Bevan Lewis,* the element of 

* " Text-book of Mental Diseases," p. 372. 



PUERPERAL INSANITY. 357 

age is also an important factor in determining the prognosis, 
patients under 30 having a much more favorable prospect 
of recovery than those considerably past that age. This 
view does not appear to be corroborated by the record of 
the 39 cases embodied in the table on page 358. 

It does not appear from this table that recoveries were 
very much hastened by early admissions. The average 
period during which the disorder had existed prior to ad- 
mission, in the first three groups, is nearly the same, while 
the period during which they were under treatment is 
doubled in the last of the three, as compared with the first. 
The same point is even more fully demonstrated in the 
succeeding groups of cases. Nor does age appear to be a 
factor of much importance in relation to the duration of 
the disease, the average being the same in first and last 
groups. Other elements, such as physical condition, hered- 
ity, and forms of disease, must be considered as important 
in relation to early recoveries. 

Case i. — A. V., age 24, had her second confinement 
about two weeks prior to her admission to the Retreat. 
A few days subsequently to confinement she became sus- 
picious, turned against her husband and friends, and thought 
she saw devils on the walls flitting about her room. She 
threatened to kill both her babe and her husband, and was 
much excited. When admitted, however, she was quiet; 
the effort incident to the journey evidently had had a sooth- 
ing effect. She had not slept during four days and nights. 
Her pulse was 90, full and soft, the skin moist, and she had 
taken but little food for several days. 



Table Showing the Averages of Time under Treatment, in Special 

Relation to the Length of Time Disease had Existed Prior 

to Admission, and Ages, in Thirty -nine Recoveries. 





Disease Ex- 


Ave- 










No. 


isted Prior to 


Recovehed. 


Average. 


Age. 


Average. 




Admission. 


rage. 










I 


3 months. 




1 month. 




35 1 
28 

43 
24 




22 
48 
62 


6 days. 

7 dajs. 

3 weeks. 


. 30 + 
days. 


3 weeks. 
I month. 
1 month. 


weeks. 


. 3if 
years. 


34 


1 month. 




1 month. 




28 J 




3 


2 months. 




2 months. 




27 1 




4 


10 days. 




6 weeks. 




36 




42 


3 weeks. 




6 weeks. 




23 




47 
55 
69 


6 weeks. 
5 weeks. 
4 days. 


..31 + 

days. 


6 weeks. 
2 months. 
2 months. 


7 
weeks. 


29 
22 
29 


28f 
years. 


70 


12 days. 




6 weeks. 




24 




84 


7 clays. 




2 months. 




32 




89 


3 months. 




7 weeks. J 




35 J 




5 


2 months. 




3 months. 




33 ] 




14 


4 weeks. 




3 months. 




20 




19 


4 weeks. 


■ 34 


3 months. 


weeks. 


22 


years. 


68 


4 weeks. 


days. 


3 months. 


23 


88 


7 weeks. 




II weeks. 




24 




95 


2 weeks. 




3 months. 




29 J 




8 


20 days. 




4 months. 




22 * 




44 


3 weeks. 




14 weeks. 




24 




46 


6 weeks. 


22 -f- 


4 months. 


. "* 


28 


, 2 3f 


49 


5 days. 


days. 


15 weeks. 


weeks. 


22 


years. 


54 


5 weeks. 




4 months. 




28 




81 


2 weeks. 




14 weeks. 




19 J 




20 


5 weeks. 




5 months. 


t 5 
months. 


24 1 




28 


9 days. 




5 months. 


26 




7 


6 days. 




7 months. 




19 


26| 


21 


16 days. 




7 months. 




33 


35 


2 months. 


'36 + 


7 months. 


y 7 
months. 


24 


" years. 


58 


6 months. 


days. 


7 months. 


30 




66 


3 weeks. 




7 months. 




26 




77 


10 days. 




7 months. 




23 - 




27 


10 weeks. 




7 months. 


I Q 


24 * 




29 
64 


3 weeks. 

4 weeks. 


[ 49 + 


9 months. 
9 months. 


y 9 

1 months. 


35 
27 


- 3 1 


9i 


4 months. 

5 days. 


days. 


10 months. 


1 months. 


35 


years. 


85 




1 1 months. 


34 - 





358 



PUERPERAL INSANITY. 359 

She was given milk and eggs, beef tea and beer, with 
chloral at bedtime, but did not sleep until the second night 
after admission. In the course of a few days she became 
utterly careless as to her dress and person, very filthy, and 
would take no food except as it was fed to her with a stomach 
tube. This state of mind continued for about ten days, 
when she began to take food more willingly and freely, 
and slept some during the day as well as at night. The 
breasts, which had been swollen, became less inflamed and 
more soft; the mind gradually became less excited but was 
much confused. The untidy habits, however, continued 
several weeks, after which the mind rather suddenly im- 
proved in the quality of its activities and in strength. She 
could answer questions correctly and asked to see her 
husband and child ; looked over the illustrated papers 
which were given her and occasionally shed tears when 
alone. After eight weeks she appeared quite cheerful and 
wished to return home with her husband when he came to 
see her, and was discharged a week later, having gained 
several pounds in flesh. 

Case 2. — E. S. D., age twenty-one, single, domestic. 
Swede. In July, 1886, she was confined. On August 24th 
she was admitted to the Asylum. Three days before admis- 
sion she had become much disturbed and talked continually 
in a very rambling and incoherent manner. She attempted 
to kill her nurse with a knife. Upon her admission she was 
very much excited and her friends reported that she had 
not slept any for three days. "She slept very little the first 
night and was quite noisy. Two days after admission she 
began to sleep at night, but did not take much nourishment. 
August 29th she is reported as mischievous, attempts to 
throw things out of the window, and to disrobe herself. 
She imagines that she owns the institution and that she 



360 LECTURES ON MENTAL DISEASES. 

can regulate the weather. She requires much personal 
attention. 

September 1st. The patient developed pneumonia of 
the upper lobe of the left lung, with a temperature of 
1 04° F. 

September 5th. She was convalescent from the pneumonia 
and began to gain in physical strength. 

September 24th. She was in fair bodily health, was quiet 
and agreeable, though at times she was found crying very 
piteously. On account of her inability to speak English, 
except very imperfectly, it was very difficult to ascertain the 
character of her delusions. 

October 17th. Her physical health was excellent. She had 
become quite fleshy; exercised good self-control, and em- 
ployed herself usefully at times, though she was still under 
the force of distressing delusions, and feared that she was 
to be killed or forced to work and not be permitted to go 
to her own home again. 

November 17th. She had no delusions which could be 
discovered, and frequently requested to be allowed to go to 
her home. Had gained about thirty pounds in flesh. 

December 16th. She was reported as fully recovered. 

Case 3. — The third case to which attention is called 
presents other elements of aetiology, and is interesting as it 
illustrates what has been stated in reference to the intimate 
connection the insanity of one period may sustain to that of 
another. Her first attack occurred during pregnancy. 

P. C, aged thirty-five, English, married, and of good her- 
edity ; has always been of correct habits, industrious, and 
of previous good health. She had exhibited symptoms of 
insanity, however, about. four months prior to the birth of 
her second child, but they were of short duration. After 
the labor she improved rapidly. 



PUERPERAL INSANITY. 36 1 

The present attack dates back to about a year ago — 
previously to the birth of the youngest child. She became 
very emotional and would laugh immoderately and then 
suddenly cry. She has often made threats of violence, but 
never any attempt to execute them. Her sleep has been 
scant, but her appetite almost voracious. She has com- 
plained of starving, although an abundance of food has 
been provided for her. She has destroyed her furniture 
and clothing, and would not keep herself tidy nor allow 
others to. 

January 5th. The patient entered the Institution in a 
broken down state of physical health, having recently ex- 
perienced an abortion. She was very feeble both in mind and 
body ; had no well-defined delusions. She suffered consider- 
ably from hemorrhages from the uterus, subsequently to the 
abortion. During the next two months the uterine trouble 
was corrected and she improved steadily afterward. She 
became pleasant and very industrious, but had delusions 
concerning her social standing, and also about her hus- 
band. 

Three months later, the patient became depressed and 
rather irritable. Her delusions became very active and did 
not change in character. Her physical health was well 
maintained. 

September 22d. The patient stated to-day that she was 
born and bred a lady, and demanded apartments and ser- 
vants suitable for her supposed condition of life. She com- 
plains of the noise and imagined ill-treatment she receives 
at the hands of her fellow-patients, but is quite noisy herself. 
She does not seem to recognize that fact. She blames her 
husband for keeping her here. 

December 16th. For the last month the patient has been 
31 



362 LECTURES ON MENTAL DISEASES. 

very comfortable. Her delusions, if they exist, are dor- 
mant, and she makes herself quite agreeable. She is indus- 
trious, tidy, and quite sociable, attends dances, parties, and 
other amusements, and is, apparently, making a very good 
recovery. 



LECTURE XIX 



INSANITY OF THE PUERPERAL PERIOD. 
(Concluded.) 

Treatment of Puerperal Insanity, Local and General — Insanity of Lactation — 
Etiology — Period of Lactation — Influence of Prolonged Lactation — 
Modes of Living — Accidents and Complications at Time of Labor — 
Effects Upon the Blood and Nervous System — Symptoms — Suspicion — 
Depression — Morbid Impulses — Sexual Excitement — Hallucinations — 
Physical Condition — Tables of Cases at the Retreat and the Connecticut 
Hospital — Illustrative Case — Prognosis Generally Favorable — Of Fifty- 
four Cases, Thirty-nine Recovered — Treatment. 

Treatment.— This is of great importance in all cases 
and especially in those which depend upon abnormal con- 
ditions existing in the uterus and its appendages. Ex- 
amination should be made at the earliest practical oppor- 
tunity, with the purpose of ascertaining what injury, if 
any, may have occurred to the neck or to the external 
parts, and also for the purpose of determining whether 
the involution of the uterus has been properly consum- 
mated, or if it is in the way of becoming so. If the lochia 
are of a fcetid character, warm and soothing lotions and 
injections should be used and the vaginal passage properly 
cleansed. In case the temperature is high, small doses 
of aconite may be given hourly, and saline mixtures 
given with a view of securing one or more evacuations 
from the bowels. Special attention should be given to 
the condition of the breasts, and the milk should be 

363 



364 LECTURES ON MENTAL DISEASES. 

removed by a breast pump. Warm fomentations and 
rubbing may also be used to prevent the formation of 
abscesses. Simple and nourishing food should be given 
often, and, if necessary, should be administered with a 
tube. Sleep is of special importance in the treatment 
of this form of insanity. It may usually be secured more 
surely by a 15- or 20-grain dose of chloral than by any 
other hypnotic. When this is contraindicated for any 
reason sulfonal or chloramid may be used with advantage. 
In some cases the bromide of sodium with cannabis indica 
has proved to be efficient in securing several hours of sleep 
each night. In those cases in which the blood is much 
impoverished cod-liver oil and cream or rich milk, with 
wine, may be given after the more active symptoms have 
passed away. Iron in some form, either alone or com- 
bined with strychnia, may be used with good results. In 
fact, iron is more often beneficial during the latter stage of 
puerperal insanity than in many other forms. 

Care should be taken from the first to secure movements 
from the bowels by the administration of the most simple 
laxatives or by the use of suppositories. It is very im- 
portant to secure frequent changes in the air of the 
rooms occupied by the patient and also to have several 
hours of sunshine in the room. As soon as practicable the 
patient should be taken from the house and into the open 
air every pleasant day, where she should pass several hours 
with her attendant if the temperature is such as to warrant 
it. Improvement in the physical condition is, in the large 
majority of cases, attended with improvement in the mental 
states. 



INSANITY OF LACTATION. 365 

INSANITY OF LACTATION. 
Etiology. — The third and remaining form of insanity 
connected with and arising from child-bearing is that of 
Lactation. It is nearly always of an anaemic type, and its 
symptoms resemble those existing in cases which arise from 
other causes producing this state in the system. This form, 
like that of puerperal insanity proper, is more likely to 
occur in females above 30 years of age ; but unlike that, is 
rarely found except in women who have borne and nursed 
several children, or when there has occurred a large hem- 
orrhage or other complication at the period of labor. In 
some cases the division between the two forms is a rather 
arbitrary one. We have already stated that puerperal 
insanity proper may not arise until several weeks after the 
labor, and consequently long after the function of lactation 
has become fully established. Such cases, however, should 
be confined to that group in which the aetiology exists in 
the abnormal conditions of the uterus itself, and has little 
or no relation to lactation. Such a distinction can generally 
be recognized, for, though both may act as causes of 
depression and greatly reduce the systemic nerve energy, 
yet lactation rarely acts in this way during the first three 
months. Indeed, it is a function so closely allied to the 
deepest maternal instincts, that nearly always the mother 
experiences greater disturbances from its suppression than 
from almost any other incident that can occur at this 
time. Whereas, the disturbances which are engendered 
in connection with the imperfect involution of the uterus 
and lesions of its neck, attended with the strain upon the 
brain incident to protracted labors, act as a powerful 
factor of irritation and exhaustion of the nerve centres, 
and always during the few weeks next subsequent to the 
termination of labor. 



>66 LECTURES ON MENTAL DISEASES. 



The period requisite for the occurrence of normal invo- 
lution of the uterus will vary somewhat in different cases 
and in the same cases in different confinements, it being; in 
some measure dependent upon the physiological condition 
of the system at the time. It may, under favorable condi- 
tions and in healthy subjects, occur after the first two or three 
labors within four or six weeks ; but is likely to be longer 
delayed in subsequent ones, especially if the labor has 
been complicated or the pregnancies have occurred with 
short intervals. In some women it is rarely complete in 
less than three months. 

The period during which nursing may, with safety to 
the mother, be continued ; must depend very greatly upon 
the physical conditions existing. Many women nurse 
much longer than is advisable for their health, with the 
object of avoiding another pregnancy ; and when the advice 
of the physician is asked in reference to the length of time 
it can be continued with safety, I think one of the most 
important points of inquiry should relate to the hereditary 
tendency. If this exists in even a small degree in the 
family, or the mother has formerly experienced conditions 
of nerve exhaustion, anaemia, or an attack of insanity, the 
child should be weaned before, or at the earliest indication 
of, any debility which appears to arise from the continuance 
of the function. Some mothers may with impunity nurse 
their children twelve months, while others should never 
pass beyond three or six. 

The influence of prolonged lactation is an important fac- 
tor which is not usually sufficiently recognized by the physi- 
cian. A large difference in the capacity for nursing and in its 
effects upon the system exists even in healthy women. While 
in some the materials essential to the formation of milk of 
good quality may be taken from the blood with little or no 



INSANITY OF LACTATION. 367 

unfavorable effect upon the system, yet with some others 
who are obliged to make much muscular exertion in labor 
it tends rapidly to diminish the fatty matters essential to 
health and vigor. 

Again the modes of living, the quality of food, and the 
habits of life exercise a considerable influence upon lactation. 
Those women who enjoy a sufficient and moderate amount 
of exercise in the open air, and take an abundance of nitro- 
genous and fatty elements in their food, are likely to become 
and remain better nurses than the more sensitive, who live 
in heated rooms with vitiated air and take but little exercise 
except indoors, especially if overworked and burdened with 
care. In such cases the drain upon the system, from the 
frequent suckling a large infant six or eight months old, 
tends rapidly to develop a state of anaemia ; and if continued 
beyond the first indications of this condition is likely to be 
followed by serious mental disorder. Again, not only 
should the heredity and the normal temperament be taken 
into consideration in giving counsel as to the continuance 
of lactation, but also the history of the confinement and 
the present environment of the individual. 

Allusion has already been made to the influence of acci- 
dents and complications at the time of labor, such as 
unusual floodings from imperfect contractions of the uterus, 
retained portions of the membranes retarding the normal 
course of uterine involution, profound impressions upon 
the brain and nervous system from the long continuance of 
pain in highly sensitive women — as being directly or in- 
directly a factor of causation in puerperal insanity. But 
this influence does not end with the involution of the 
uterus; and while, in any given number of cases, it may 
not prove to be sufficient to cause the development of 
insanity during the first few weeks succeeding labor, yet 



368 LECTURES ON MENTAL DISEASES. 

in connection with other agencies at a later period it may 
prove to be very important. The effect is always from the 
first of a lowering character. The store of nerve energy 
becomes lessened and the inhibitory centres weakened. 
The system, therefore, is in a much less favorable state to bear 
the experience of a protracted period of lactation than it 
would be if no such complications had occurred. The nerve 
centres have experienced a profound shock and strain, or the 
blood has been so greatly diminished that it cannot fully 
regain its normal constituents of red corpuscles and fibrin 
while lactation is carried on, and the patient tends rapidly 
toward an anaemic state. 

Among the poor, too (and it should be borne in mind 
that lactational insanity is much more common with them 
than with those who are favorably conditioned), the hygienic 
environment is often most unfavorable. The food is gener- 
ally of poor quality and improperly cooked ; .the child may 
be ill and restless at night, so as to prevent the sleep of the 
mother. She generally has the care of several other small 
children and also of the whole household, and all the while 
is living in the sexual relations of a wife. In short, the 
whole physical and mental system experiences such expo- 
sures and hardships as must test the most robust, and only 
such are able to pass through them with impunity. The 
more delicate and sensitive, and especially those having an 
hereditary tendency, are those who succumb. In review- 
ing, therefore, the serological elements as above presented, 
it will be observed that while lactation, to which has been 
assigned the first position, has determined the nomenclature 
of the disease and should properly be made prominent, yet 
it has associated with it in the larger proportion of all cases 
other elements of causation the relative importance of which 
will vary very much in different cases. 



INSANITY OF LACTATION. 369 

Symptoms. — The symptoms may be of an excited or 
depressed type, but in either case they are generally of a 
more transitory character than in other forms of insanity. 
Sometimes, though rarely, they partake of the character of 
dementia. The record of eleven cases which have been in 
the Connecticut Hospital shows that in seven of them the 
symptoms of mania were present; in three, those of melan- 
cholia; and in one, those of dementia; these figures indicate 
that 63 per cent, were cases of mania and only 27 per cent, 
were cases of melancholia. This corresponds very closely 
with the experience of Dr. Bevan Lewis in his statistics, 
comprising 66 cases. But in Dr. Clouston's experience 
with 50 cases, the states of excitement and depression were 
quite evenly divided — 21 being somewhat excited and 19 
being mildly depressed. The degree of excitement or 
depression is generally less than pertains to other acute 
insanities and yields more quickly to the effects of remedies. 

The first mental indications are those of doubt and 
suspicion, especially of the husband and those that sustain 
the nearest family relation. Whatever may be said or done 
is very likely to be misjudged and wrongly interpreted by 
the patient. These mental states, with a mild form of 
depression, may continue for three or four weeks and fre- 
quently longer before the patient becomes excited, some- 
what noisy, and incoherent. The degree of excitement 
varies considerably in different patients. Some become 
very noisy, aggressive, abusive in language, violent, and 
destructive, and largely dominated by imperative concepts 
of fear and delusions of impending danger. They imagine 
that their most intimate friends are conspiring against them, 
and endeavor to protect themselves by attacking them. 

Morbid impulses are not infrequently present in mani- 
acal cases, especially when the patient is anaemic, feeble, 
3 2 



3JO . LECTURES ON MENTAL DISEASES. 

weak, and the general physical condition has become 
greatly reduced before the onset of the disorder. In such 
cases the hallucinations appear to be more intense and 
vivid and their effects are quite like those existing in ordi- 
nary puerperal insanity. It is impossible to predict what is 
likely to be the course of conduct at any time, and some- 
times patients become highly dangerous. 

In those patients whose symptoms do not assume a mani- 
acal type, the conditions of depression and melancholia 
generally become more pronounced as the disease advances. 
They believe that they are ruined and are soon to be 
punished or publicly disgraced, and hence require the most 
careful and constant observation lest they attempt suicide. 
Under the effect of delusions of persecution and impending- 
danger they frequently refuse to take food and declare that 
it has been poisoned. 

Manifestations of sexual excitement as evinced in lan- 
guage and behavior are less frequent in cases of lactational 
insanity than in those of puerperal insanity proper, and feel- 
ings of strong aversion toward the husband are common. 
The wide difference in the physical conditions existing in 
the two forms of disease doubtless accounts for this. 

Hallucinations of both sight and hearing are very com- 
mon and generally form the basis from which delusions 
arise. Suicidal tendencies are present in from fifteen to 
twenty per cent, of all cases, and develop from the fear and 
dread of some impending calamity. In the more acute cases 
it has been observed that the symptoms develop during the 
first four or five months and the patients are more likely to 
become restless, suddenly irritable, excited, noisy, and 
talkative, without any preceding period of depression. 
Thoughts become incoherent and rambling and have little 
sequence or order. But the history of the larger propor- 



INSANITY OF LACTATION. 371 

tion of cases indicates a slow development, and patients 
rarely pass suddenly into a maniacal or dangerous condition ; 
the developmental period usually extends over several 
weeks, during which the patient is more or less restless and 
depressed and presents indications of physical and mental 
weakness. Insomnia is often present both during the 
initial and excited stages of the disorder. 

The physical condition is one of debility. The patient 
is anaemic, weak, and thin in flesh. The pulse is increased 
in frequency and easily compressed ; the face and lips are 
pale, and complaints of pain of a neuralgic character in the 
head, flashes of light, lumbago, dragging sensations about 
the lower portions of the back, noises and ringing in the 
head and ears, etc., are very commonly made. 

The tables on pages 372 and 373 are of interest, as they 
indicate the symptoms and results in the cases which have 
been studied as a basis for this lecture: — 

The following case presents in a mild form some of the 
more common symptoms and physical conditions which 
are found to exist in lactational insanity. As will be 
observed, the general health was much below its ordinary 
state, possibly, in the first instance, from strain and nerve 
exhaustion incident to teaching, and secondly from the 
effects of the prolonged labor and instrumental delivery. 
These causes, together with the drain upon the system, in 
its effort to nourish the child, proved sufficient to upset the 
brain, though there does not appear to have been any 
history of heredity in the family. 

C. A. H., age thirty-three, married about fifteen months. 
Had been for fifteen years previous a school teacher, and on 
one or two occasions broke down from nerve exhaustion 
and was unable to teach for several months. Now has a 
child three months old. The labor was prolonged and the 



372 

CASES OF 



LECTURES ON MENTAL DISEASES. 
INSANITY OF LACTATION IN THE RETREAT, 



Age. 


Heredity. 


Symptoms. 


Result. 


Subsequent History 
and Remarks. 


24 


Not 
stated. 


Melancholia. 


Now under treat- 
ment. 


None. 


23 


Not 
stated. 


Melancholia. 
Suicidal. 


Recovered in 5 
months. 


None. 


37 


Denied. 


Melancholia. 


Much improved 
in 5^ months. 


None. 


32 


Not 
stated. 


Mania. 


Recovered in 3 
months. 


Has five children. 


27 


Not 
stated. 


Mania. 


Much improved 
in 5 months. 


Had had one pre- 
vious attack. Has 
six children. 


39 


Not 
stated. 


Mania. 


Improved in 17 
months. 


Had one previous at- 
tack. Has seven 
children. Read- 
mitted once. 


22 


Not 

stated. 


Mania. 


Recovered in 6 
weeks. 


None. 


37 


Sister in- 
sane. 


Melancholia. 
Suicidal. 


Recovered in 3 
months. 


Has six children. 


29 


Not 
stated. 


Melancholia. 


Much improved 
in 4 months. 


Has three children. 



CASES OF INSANITY OF LACTATION IN CONNECTICUT 
HOSPITAL FOR INSANE* 



Age. 


Heredity. 


Symptoms. 


Result. 


Remarks and Subse- 
quent History. 


25 


Denied. 


Mania. 
Demented. 


Now under treat- 
ment. 


None. 


30 


Not 
known. 


Mania. 


Recovered in 10 
months. 


Had one subsequent 
attack. 


28 


Not 
stated. 


Mania. 


Now under treat- 
ment. 


None. 



* Furnished by Dr. James Olmsted, Superintendent. 



INSANITY OF LACTATION. 



373 



Age. 


H 

Heredity. 


Symptoms. 


Result. 


Remarks and Subse- 
quent History. 


36 


Denied. 


Mania. 


Recovered. 


Readmitted once and 
discharged station- 
ary. 


26 


Not 
known. 


Melancholia. 


Now under treat- 
ment. 


None. 


30 


Brother 
insane. 


Dementia. 
Suicidal. 


Improved. 


Was insane after sec- 
ond and third con- 
finements. 


36 


Mother 
insane. 


Melancholia. 


Improved. 


Readmitted twice. 


19 


Doubtful. 


Mania. 


Recovered. 


None. 


29 


No. 


Melancholia. 


Now under treat- 
ment. 


None. 


34 


Mother 
had pu- 
erperal 
insanity. 


Melancholia. 


Improved. 


Had one previous at- 
tack of lactational 
insanity. 


37 


No. 


Melancholia. 


Recovered. 


None. 


34 


No. 


Mania. 


Recovered in 13 
months. 


None. 


32 


Not 
stated. 


Melancholia. 
Suicidal. 


Recovered. 


Had eight children 
in twelve years. 



delivery instrumental. She has been about as usual and 
nursed the child, though feeling weak and unable to make 
any exertion. Finally she was brought to the hospital for 
the purpose of building up her general health, and after 
admission there became affected with hallucinations of 
hearing, and thought persons were calling to her. She 
made efforts to reply to these voices, and after a few days 
became so much excited and noisy that she was transferred 
to the Retreat. On admission she was despondent and 



374 LECTURES ON MENTAL DISEASES. 

unable to sleep except with medicine, looked thin and 
anaemic, but was able to reply to all questions when her 
attention was secured. She continued to talk to herself or 
to imaginary persons in a rambling and incoherent manner, 
and was greatly despondent. She was at once put upon 
the use of the hypophosphites and an abundance of food, 
and took hydrobromate of hyoscine for sleeping at night. 
She continued for some two or three weeks to imagine 
that some calamity was impending, and that she was fast 
failing and should never recover ; that she was liable to die 
at any moment. She was suspicious and would not believe 
what was said to her; but in spite of all her forebodings 
she slowly gained ; the hallucinations became less and her 
strength improved until she was removed by her friends, 
and though she was still in a condition of debility and 
could not be regarded as fully recovered, yet I have no 
doubt she did recover at her own home. 

Prognosis. — The prognosis in lactational insanity is 
generally favorable. By reference to the preceding tables 
it will be observed that of nine cases in the Retreat, four 
recovered, and three, were so much improved within five 
months (i. e., were so nearly recovered) that they were 
removed by friends ; as they did not return, they may be 
considered as recovered. The recoveries, therefore, 
amount to Jj per cent. One of the remaining two was 
discharged as improved. She had experienced one pre- 
vious attack, had borne seven children, and was admitted 
once afterward. The remaining one is under treatment. Of 
the 13 in the Connecticut Hospital six recovered; those 
who were discharged as improved had experienced former 
attacks, and two more of them had subsequent attacks, while 
four are under treatment. Of 54 cases reported by Dr. J. 
Batty Tuke, 39 recovered. Dr. Clouston reports actual 



INSANITY OF LACTATION. 375 

recoveries amounting to 77.5 per cent, and with a still 
higher percentage as probable, some of the patients having 
been removed before recovery was complete. In the analy- 
sis of results as reported by Dr. Bevan Lewis the percent- 
age of recoveries is 65.6. 

Treatment. — The indications for treatment are readily 
suggested by the physical states which are present in the 
larger number of cases and can hardly be mistaken. Those 
cases which are affected with the milder form of mental 
derangement can be easily managed in their own homes if 
the conditions of living are favorable and good nurses can 
be secured. Indeed, no inconsiderable number are thus 
cared for as are indicated by the statistics of asylums. The 
aversion toward removing such cases from home is greater 
than exists in patients affected with some other forms of 
insanity. 

It is, however, better that the larger proportion of 
patients should be removed from the influences and respon- 
sibilities connected with home life and placed beyond con- 
tinual reminders of them. They require to be relieved 
from the friction and irritation which comes from the care 
of young children and which has probably been a factor of 
causation. Freedom from care of self and others, reg-u- 
larity in the use of food in large variety, favorable condi- 
tions for securing an abundance of sleep, new scenes and 
skillful nursing, all tend to place the patient in the most 
favorable environment for recovery. The prospect of 
recovery, which can be stated to friends, will act as a 
strong inducement toward leading them to place the patient 
in the care of some institution. As preliminary to this, 
however, it is desirable to wean the child if this has not 
already been done. 

The first point of importance in the treatment after 



3^6 LECTURES ON MENTAL DISEASES. 

admission to an institution or at home is the administra- 
tion of an abundance of highly nutritious food. This 
should be given as often as every four hours, or at least 
five or six times in the course of 24 hours. It should 
consist of milk and eggs, beef extract or strong broths, fish, 
and easily digested meats. Uncooked eggs beaten up with 
wine or cider are generally relished and will take the place 
of solid food if this is refused. A glass of milk taken before 
retiring, or when awake during the night, will often be of 
service and tend to allay restlessness. 

In cases of insomnia, hyoscine, sulfonal, chloralamid, or, 
in case any one of these should not produce sleep, chloral, 
may be used for a few nights. If an abundance of food is 
taken the use of the above hypnotics at bedtime for a 
short period will generally be sufficient to prepare the 
system for sleep without the use of any hypnotic afterward. 
Opium should not be used unless in those cases in which 
depression is present, and then should be combined with 
the bromide of sodium or bromide of ammonium. Bitter 
infusions, quinine, wine or malt liquors, cream or cod-liver 
oil, and the free use of eggs, with gentle exercise in the 
open air by riding or walking, will tend rapidly toward a 
cure. Fowler's solution will sometimes be of essential 
service. It should be given in small doses at first, three- or 
four-minim doses three times a day, and may be increased 
from week to week according to indications. Rubbing and 
warm salt baths are also important in some cases ; but it 
should be remembered that, after all, an abundance of 
easily digested food of good quality, in small quantities 
and frequently used, is a prime necessity and will conduce 
toward recovery more than any other one thing. 



LECTURE XX. 



INSANITY OF MASTURBATION. 

/Etiology — Effects of Sexual Derangement upon the Mind — Anxiety — Seminal 
Emissions — Neurotic and Sanguine Temperaments — Hereditv — In Cases 
of Adolescent Insanity Masturbation is Often a Consequence Rather than 
a Cause — Symptoms — Debility — The Circulation — Appetite — Seclusion — 
Depression — Irritability — Cases — Diagnosis — Religiosity — Dislike of the 
Opposite Sex — Tendency to Seek Isolation — Short Periods of Self- 
importance — Prognosis — Treatment — Importance of Labor in the Open 
Air, etc. 

./Etiology. — The connection and sympathy existing 
between the intellectual and sexual centres of the brain 
and their reciprocal influence have long been recognized as 
most intimate. 

A lack of development in the sexual organs, at that 
period of life when they usually come into normal activity, 
is nearly always attended with a corresponding weakness 
and childishness of the mind ; and it is only when the 
sexual organs become fully developed that the mind passes 
into the freedom and courage of manhood. Further, this 
influence continues to old age, and a derangement of no 
function or system sooner manifests itself on the mind than 
that of the sexual organs. 

Indeed, it is not always necessary that the change in 
functional activity be an actual disorder to raise anxiety 
and forebodings. Often a mere change in sexual feeling, 

377 



$7$ LECTURES ON MENTAL DISEASES. 

especially if it is one of lessened or irregular activity, which 
may be due to some unusual experience, when long pro- 
tracted, or an undesired excitement of the organs, may 
prove quite sufficient to arouse this anxiety and render the 
individual miserable for the time being. Hence almost 
every practitioner of medicine has had numerous visits 
from young persons who nearly all come with a similar 
story, which runs somewhat as follows : that when young 
boys they had learned from older ones the wretched habit 
of self-abuse ; that they occasionally practiced it for years, 
or until they learned in some manner that it was wrong, 
or became convinced of it by its effects upon themselves ; 
that since such discovery they have abandoned the habit, 
but have been subject to seminal discharges; that these 
experiences, which have occurred as often as every two or 
three weeks or oftener, they feel confident, are producing 
a very bad effect upon their general health, are, in fact, 
sapping its very foundation. 

When asked for the reason on which they base such 
conclusions, they can only reply, in a general way, that they 
feel languid and fatigued after wakening in the morning; 
that they frequently do not sleep so soundly as in former 
times ; that they are subject to occasional headaches and 
unpleasant dreams, and constantly harassed with fears as 
to their future health and manhood. 

When questioned more definitely as to any actual change 
which has already taken place, whether they are disabled 
from labor, or have lost flesh or strength, or have any 
actual pain or debility which disqualifies them from per- 
forming their usual duties, they are forced to admit that no 
such results have already occurred. They, however, are 
constantly haunted with the expectation that they will soon 
come, and hence they beg you to prescribe such remedial 



INSANITY OF MASTURBATION. 379 

and preventive measures and medicines as will be sure to 
save them from such experiences. 

Another class, less numerous than that already referred 
to, come with a similar story, except that they did not 
learn of the evil effects of the habit until after long years 
and an excessive indulgence in it. 

Many of them have attained this knowledge at last only 
by the debility which has occurred in the sexual organs, or 
from some stray quack advertisement of a newspaper, the 
full meaning of which they have hardly comprehended. 
When finally they have determined to abandon the habit, 
they find themselves greatly annoyed and weakened by 
frequent seminal discharges. These have continued so 
long that the subjects experience a debility of both mind 
and body ; they lose flesh, have occasional night-sweats, 
and wretched dreams; have lost interest in their usual avo- 
cations and the society of friends, and think they are 
unable to become interested in either study or labor, how- 
ever much they may endeavor to do so. They have 
become timorous, emotional, easily excited, and often rest- 
less, and have frequent foreboding as to their future, and, in 
short, are in a state of mind to believe almost anything, 
however bad and hopeless it may be, in reference to the 
probabilities of their case. Indeed, generally the more 
unfavorable the prognosis of any physician may be in 
reference to their future, the more serious and alarming 
the statements he makes in reference to the necessity for 
immediate and skillful treatment, the more ready are they 
to place confidence in his statements, and regard that phy- 
sician as the one who fully understands their case. 

These are the unfortunate ones who are preyed upon by 
medical sharks who prowl about through almost all large 



380 LECTURES ON MENTAL DISEASES. 

towns and cities and parade their vile advertisements and 
nostrums on the pages of our daily papers. 

The following is a very good illustration of this class of 
cases : — 

A young man about twenty- four years of age came to me 
with the statement that he had recently become engaged to 
be married ; that now he was in great distress of mind and 
was hardly able to sleep because he found he should not be 
able to consummate the marriage relation ; that when a 
boy he had learned to masturbate and practiced it for 
several years, but had for a long time given it up, since 
which time he had been subject to seminal discharges at 
times, and there existed little or no sensation about the 
genitals ; they were lax and flabby, and he had no doubt 
that his semen was running away from him every time he 
had an evacuation of the bowels. He was fast losing flesh 
and vigor, and something must be done at once. Now, it 
is of very little use to tell such a person that his condition 
is far less grave than he supposes, and that he need not be 
alarmed, that he is sure to come out all right if he goes 
on the even tenor of his way — that he does not require 
much from the physician in the way of treatment. Such a 
statement, instead of assuring and comforting him, as you 
design to have it, will only lead him to think that you do 
not understand his condition, and in nine cases out of ten 
he will leave your office and hunt up that of some physi- 
cian, or more likely that of some quack, who will tell him 
that his condition is indeed a very grave one, but that he 
can, in two weeks' time, set him all right, and put him into 
a condition to be married, which he proceeds to do at a 
charge of fifty or one hundred dollars. 

Persons comprising the above-mentioned classes are 



INSANITY OF MASTURBATION. 38 1 

generally of a neurotic or sanguine temperament; they are 
highly sensitive to objective and subjective experiences, and 
will require special moral, and occasionally medical, treat- 
ment, but they rarely become insane. 

What I desire to call special attention to in connection 
with this mention of them now is the marked effect which 
has been produced by the habit of masturbation upon those 
centres of the nervous system upon which the emotional 
activities depend; sooner or later these may become greatly 
influenced or deranged by such practices in persons of a 
highly sensitive and nervous organization ; and more often 
long before marked physical changes occur. 

There is yet another class which does not often come 
under the attention or care of the general practitioner. 
These persons differ from those already alluded to in that 
they generally have an inheritance of insanity, or some 
other neurosis ; one or the other of the parents has either 
been insane or consumptive, or addicted to the excessive 
use of alcohol, or other vices. 

When the system is burdened with such an inheritance, 
and the inhibitory centres are undeveloped or anaemic, or 
an unstable condition of the brain exists from any other 
cause, the practice of self-abuse is more likely to become 
excessive, and appears to produce a more profound influence 
upon the intellectual faculties ; the brain is more susceptible 
to its effects, and manifests this by a derangement of its 
activities and a failure in its energy in such forms as are 
hereafter to be referred to. It may therefore be assumed that 
the effects of the habit of masturbation upon individuals will 
differ very much and will depend primarily upon the age, 
constitution, temperament, and inheritance. 

The very young and sensitive and illy-balanced individual 
will become more nervous and sensitive, and therefore 



382 LECTURES ON MENTAL DISEASES. 

apprehensive of effects which he is all the time magnifying 
and regarding as sure to become greater in the future, while 
another, who has a lymphatic temperament and a larger 
measure of inhibition, tends toward reserve and hesitation 
and is disposed to shun society, especially that of females. 

It should, however, be remarked that by far the larger 
proportion of young persons who are insane and addicted 
to this habit while in this state, are not insane as a conse- 
quence of its former practice. The habit is a consequence 
and not a cause of their disease. 

A super-sensitive or excited condition of certain portions 
of the brain, which has resulted from other causes, not 
unfrequently extends to those portions which preside 
over the sexual organs, and these in consequence are 
aroused into a morbid activity, which leads the patient 
into the practice. This is especially the case with females 
who become affected with what is termed nymphomania, and 
are occasionally found in all asylums. I very well remember 
such a case in the person of an old woman more than 
seventy years of age who must have been dead to all 
normal sexual feelings for years, whose conduct was so 
indecent as to require her seclusion for considerable periods- 
It is not unfrequently the case with highly excited and 
maniacal patients, and especially with those who are partially 
demented ; and so long as the nerve centres are exhausted 
by the continual practice of this habit there exists little 
probability of improvement in the mental condition. 

Symptoms.— As has already been intimated, there are 
cases in which the habit becomes the chief factor in causing 
mental derangement. The records of many such are 
found in the journals of all asylums. It almost always 
arises during the period of adolescence, though it may also 
appear at the grand climacteric, and even in old age; and 



INSANITY OF MASTURBATION. 383 

is quite likely to appear during the latter period if it has 
existed in the first. 

Indulgence in excessive sexual intercourse when long 
protracted ordinarily tends to produce a profound impres- 
sion upon the nervous system, and is attended by debility 
and depression. It has also been regarded as one of the 
most efficient causes of general paralysis. While we have 
no reason to suppose that masturbation may be regarded 
as a cause of that form of disease, yet its effects upon the 
nervous system are very injurious, though they terminate 
in a different form of disease. The symptoms are in some 
respects such as would be anticipated from the effects of a 
large drain upon the system — namely, those of debility. 
The individual loses flesh and nerve; the hands are often 
cold and clammy; the action of the heart is easily dis- 
turbed and irregular ; sleep is broken and lessened ; the 
appetite capricious, the tongue soft and indented from its 
pressure upon the teeth; food is not well assimilated; and 
the person complains more or less of debility and general 
wretchedness. 

After a longer or shorter duration of these physical con- 
ditions, or in connection with them, the symptoms of 
change and derangement of the mind appear. The person 
is inclined to seek seclusion and shuns society, especially 
that of females ; will not look you in the eye, prevaricates, 
deceives ; has little of settled purpose, becomes depressed, 
and not infrequently exhibits a suicidal tendency. The 
depression, however, does not amount to melancholia, nor 
does the general appearance of conduct at all resemble that 
of a person affected with that form of disorder. This con- 
dition does not usually continue very long under the quiet, 
regularity, and publicity of asylum life, and is often suc- 
ceeded by one of irritability, self-importance, and self-satis- 



384 LECTURES ON MENTAL DISEASES. 

faction, a readiness to easily take offense, and quarrelsome- 
ness. The patient is disposed to think he is insulted by 
attendants or patients or that he is neglected. He loses 
all sense of modesty, and is ready to talk of his disgusting 
habit, though he rarely openly practices it, as is sometimes 
the case in the excitement of maniacs. 

Case i. — The following case, E. A., age twenty-five, was 
admitted in July, 1884, and will illustrate some of the above- 
mentioned conditions. He is reported to have been so 
much of an invalid for years as to necessitate his remaining 
in bed much of the time ; is of a neurotic temperament, and 
has been for several years excitable. About a year ago he 
began to have nervous twitchings of the muscles about the 
neck, of a choreic character, and a short time before admis- 
sion began to express delusions of fear; thought efforts 
were made to poison him ; that he was to be arrested, and 
he sought to leave home on this account and to secrete 
himself; has suffered from insomnia; endeavored to com- 
mit suicide once by hanging, and once by jumping from a 
second-story window. He has been a masturbator for 
many years. 

After his admission he was somewhat incoherent, dull, 
and listless, and when he talked spoke in a rambling, 
meaningless way ; was pale and anaemic ; heart action 
irregular; hands cold and clammy; he became easily dis- 
turbed and excited, and inquired where he was. After two 
or three days a camisole was applied to prevent his mastur- 
bating and with good effect. He soon began to give indi- 
cations of more mental action, and even requested that it 
might be kept on him ; said that he had long been addicted 
to the bad habit, and desired to break it off; whenever 
the camisole was removed he was kept under close obser- 
vation. After some weeks he again became excited, talked 



INSANITY OF MASTURBATION. 385 

incoherently, and often attempted to assault either the 
patients or attendants, was exceedingly vulgar in his lan- 
guage, and threw his clothing from the window. At other 
times he became " foolish and silly," and would laugh in a 
hysterical manner, and declaim in a loud tone about the 
hall. Occasionally he complained of a pain in his back, 
and this was blistered. He continued to wear a camisole at 
night for several months, which were passed in a condition 
of mind which was often changing, at times for the better, 
and again for the worse, apparently depending upon the 
control exercised over the vicious habit. He then im- 
proved more decidedly, and was removed to his home. 
Before going he wrote the following letter : — 

March 17, 1880. Hall 4. 
Dr.:— 

Dear Sir. — What follows you will see is entirely a private matter. 
I have been thinking a good deal, at different times, about having an 
operation performed to partly destroy my sexual organ. It seems to 
me there must be an unnatural amount of excitement there, which is 
entirely spontaneous and beyond my control. I think that it averages 
three times a week that I wake up nights with disturbances of this 

kind. As I told Dr. I have been free from masturbation since 

the holidays, and was for some time before, and I intend to keep 
myself free from it in the future, but this spontaneous excitement con- 
tinues for all that. I mean to have one of my stones taken out. I 
know that this is rather an extreme measure, but I would rather have 
that done than to be disturbed and distressed as I have been in the 
past. I think this excitement has something to do with my rapid cir- 
culation, and that the trouble in my back was caused through sexual 
excitement. I want to do everything I can to restore my health, and, 
unless this operation would be likely to destroy the sexual organ 
entirely, I would really like to have this done. 

I remain yours truly, E. A. 

The operation, however, about which he writes so 
rationally, was not performed, and he went home, where in 
33 



386 LECTURES ON MENTAL DISEASES. 

a short time he again resumed the unnatural habit, became 
excited and confused ; he began to appropriate property 
belonging to others, and was returned to the asylum, 
where after a few weeks he passed into, a partially demented 
condition, in which he was often engaged in asking the 
most trivial questions and in writing meaningless commu- 
nications. A camisole and vesication were employed to 
prevent his self-abuse, but they were only of temporary 
service, and after some months of mental vacuity he became 
comatose and died. This person had been physically ill 
for so long a period, in consequence of his habit before his 
mind became disordered, that there existed from the first 
little prospect of any permanent improvement. 

Another case is under observation at the present time 
which will illustrate some different phases of the disorder. 

Case 2. — E. S. B., age twenty-three, has been a mas- 
turbator, according to the statement of friends, for more 
than five years, very probably nearer ten. Two uncles and 
an aunt on father's side have been insane. He has led a 
life of confinement for several years, and been engaged in 
study when he was not at work as a telegraph operator. 
It was reported that he had had a fair degree of physical 
health, but the mind had been disturbed for about a year 
and a half; that he had been in different portions of the 
country and in two asylums for short periods. At times 
he had appeared to be demented, and at others had delu- 
sions of apprehension, was irritable and moody, and refused 
to eat. When admitted the circulation was feeble and the 
expression of the countenance dejected and miserable; the 
tongue was coated, speech and gait slow and feeble, and 
his replies to questions very brief. Measures were at once 
adopted to improve his general health. He was compelled 
to take eggs, milk, and beef tea, frictions were applied to 



INSANITY OF MASTURBATION. 387 

the extremities, and after a few days he was taking an 
abundance of food. 

A vesicating fluid was applied to the penis, which 
measure was reinforced by a plenty of earnest counsel ; 
under the influence of such a course of treatment, carefully 
followed up, he soon began to show indications of improve- 
ment, and after a few months was able to write a connected 
letter to his father, and even expressed a desire to be 
employed about the institution ; took daily exercise by 
walking, and did some writing. His improvement, how- 
ever, did not continue. He again resumed his unnatural 
habit, fell off, became irritable, despondent, refused to take 
food, persisted in lying on the floor in the corner of his 
room, and submitted to the local treatment again, exhibit- 
ing no shame, and with apparent indifference. This indif- 
ferent condition was followed by a disposition to quarrel 
with everybody who presumed to differ from or interfere in 
any way with him. He would strike and kick and use the 
most vulgar and filthy language. He wrote to his mother 
that he had horns growing out on the top of his head, and 
at times his conduct was so coarse and brutish that such 
appendages might not have been inappropriate. At other 
times he would stand in his room or on the hall during 
hours if permitted and allow the saliva to run out of his 
mouth and down upon his clothes; refused to take medi- 
cines or try to help himself in any manner. His feet and 
hands became cold, the heart action weak and irregular. 
These conditions have been followed by periods of improve- 
ment, which have not been permanent; he has continually 
had relapses, until his prospects for any permanent recovery 
are about nil, though he has not yet become permanently 
demented. 

One of the most remarkable cases of masturbation which 



388 LECTURES ON MENTAL DISEASES. 

has ever come under my observation was in the person of 
a little girl six years of age. Her mother died before she 
was two years old. When my advice was sought in the 
case, she had not become technically demented, but still had 
lost control of herself in respect to this habit, and never 
had exhibited any true appreciation of, nor could she be 
made to understand, its nature. The case is of interest as 
showing, first, that the habit may arise without instruction 
from another, and may be continued even when the most 
stringent precautions are taken to prevent it ; and, second, 
that it may begin at a period of life long before the sexual 
organs become fully developed, in a case where a neurosis 
has been inherited. In some respects it resembles those 
cases of children whose parents or grandparents have 
long been subject to the use of alcohol, and in whom a 
morbid appetite for some form of stimulant appears when 
they are very young. 

Her stepmother brought her to me with the following 
statement : That more than a year before the parents had 
observed that the child was becoming emaciated, pale, and 
delicate, that she was inclined to remain indoors and did 
not care to play with other children. They became 
anxious, and carefully endeavored to improve her health by 
change of air and medicines. After a month the mother 
accidentally discovered the child in the act of masturba- 
ting. The evil effects of the habit were at once explained 
in the plainest language, and every effort made to dis- 
suade her from its practice, even to whippings, but all to no 
purpose. She protested that she could not help it. Her 
hands were fastened, but in her childish simplicity she said 
her thighs would not keep still, and it was found that the 
excitement was kept up in this manner; her legs were then 
fastened together, but without any favorable result. She was 



INSANITY OF MASTURBATION. 389 

reasoned with and taken to a physician to be talked to by 
him, and finally he was requested to have his surgical instru- 
ments shown to her with a statement that unless she could 
overcome this habit it would become necessary to use the 
sharp knives in some terrible operation on her body. The 
result maybe inferred by what she said to her mother after 
leaving the surgeon's office, and while holding her mother's 
hand in walking home : " Mother, those instruments did 
not look half as bad as I expected they would." The 
child resided in another State, and I have never been able 
to learn of what disease her mother had died, nor what 
became of the child. 

Diagnosis.— Some of the symptoms of masturbational 
and pubescent insanity are similar. Indeed, these two genera 
are closely allied, both being primarily dependent upon a 
neurotic or highly impressionable nervous system, inherited 
or acquired ; and yet the former may be differentiated from 
the latter, both by the general character of symptoms 
present and in the course and termination of each form. 

The extent of physical debility and derangement of the 
different functions is greater in insanity of masturbation. In 
pubesent and adolescent insanity the mental depression and 
melancholia are more pronounced, while suicidal tenden- 
cies, hallucinations, delusions, coarseness, and vulgarity of 
language are rarely present. A religious state of mind, an 
avoidance and dislike of the other sex, a tendency to isola- 
tion, occasionally short periods of self-importance and con- 
ceit, with irritability and fickleness of purpose, are especially 
characteristic of masturbational insanity. 

The prognosis in cases of insanity from masturbation is 
not usually favorable. The individual may be improved 
under the discipline and care of an asylum, and the mental 
activities become much more normal, but a relaxation of care 



39° LECTURES ON MENTAL DISEASES. 

and discipline in my experience has almost always led to a 
relapse, and the second condition is worse than the first. 
As the predisposing element of causation consists in a neu- 
rosis which has been inherited, and as this has been devel- 
oped in the large majority of cases during the sensitive 
periods of puberty and adolescence by the practice of the 
habit, the effects upon the brain become very profound and 
difficult of removal. In this respect the supersensitive 
and unstable condition resembles that which obtains in 
epilepsy. 

Cases which have arisen in persons of a vigorous habit 
and stable condition of brain, by learning the practice from 
others, rarely become insane, and the vice is generally over- 
come by education and the progress of physical develop- 
ment. 

Treatment. — The bromides serve largely to lessen the 
sexual excitement, and if used in connection with vesica- 
tion of the prepuce or the camisole, or both these agencies, 
will control the morbid tendency in some degree, while the 
system has an opportunity to recuperate ; but these meas- 
ures cannot be followed up indefinitely, and whenever they 
are abandoned the old habit of excitement only too surely 
resumes its sway. The use of pins in confining the prepuce 
or other surgical treatment of the penis proves to be of no 
better service. Moreover, there always exists in these cases 
a demoralization of the moral element which does not pass 
away with the physical improvement, and no amount of 
instruction as to the absolute necessity of reform ever avails 
very much. 

The individual may, under the power of returning reason, 
as in one of the cases detailed, be willing to suffer mutilation 
as a remedy, and yet not have the courage and grip of 
resolution to stand up against a resumption of the wretched 



INSANITY OF MASTURBATION. 39 1 

practice, and again returns, as the hog, to his wallowing in 
the mire. 

One of the most efficient means of fortifying the will in 
its effort at reform, if there exists any, is physical labor 
and life in the open air. These conditions will tend to 
equalize the circulation and eliminate the nervous energy, 
or turn it into other channels. There exists no doubt that 
in the large majority of cases the long-continued practice 
has led to a super-sensitive or hypersemic condition of the 
nerve cells or sexual centres of the brain, which may be 
akin to the condition of certain areas of the cortex in some 
cases of epilepsy or of chronic alcoholism. A condition of 
good feeling and self-importance exists at times in both 
these disorders, which is like that which is present in many 
cases of general paresis, though it is much less persistent, 
and is not so extreme. The long-continued and often- 
repeated excitement attending the practice finally so far 
weakens the brain that the condition of hyperaemia becomes 
chronic ; it ultimately gives way to a failure of nervous 
energy, and the mind passes into a consequent dementia, 
toward which the large majority of such cases tend. 

Some of the more favorable cases which occasionally 
come to asylums may be benefited by such measures as 
have already been alluded to, supplemented by the use of 
nux vomica, the hypophosphites, and iron. Any course of 
treatment, however, must be followed up for a long period, 
and then, if successful, the person may be advised to con- 
tract marriage. ' • 



LECTURE XXI. 



EPILEPTIC INSANITY. 

Epilepsy and Insanity — Characteristics of Epileptics — Tendencies to Mental 
Derangement — Responsibility of Epileptics — Epileptic Neurosis — Charac- 
teristics of — Symptoms of Epilepsy — The Aura Epileptica — Phenomena 
Attending It — Hallucination of Any of the Special Organs of Sense — A 
Case — Swedenborg — The Aura May Affect both Sight and Hearing — 
A Case — " Petit Mai " — Symptoms of— Age — " Grand Mai " — Symptoms 
of — Derangement of Mind — " Epileptic Fury." 

Among the several neuroses one of the most, if not the 
most, influential in causing mental derangement is that of 
epilepsy. In fact, the epileptic and insane neuroses are so 
closely allied in character that they are interchangeable in 
their hereditary tendencies, and the offspring of parents 
possessing either of them may have the other. The leading 
characteristic of both is instability of nerve tissue. The 
one manifests itself in morbid sensibility and motility, and 
the other in morbid mentality, and the first not unfre- 
quently passes over into the second. This passage is more 
commonly a slow one, and may cover a period of years, 
though in cases in which the convulsions are of a very 
pronounced character they may develop insanity early. 

Esquirol found that two-thirds of the epileptics in la Sal- 
petriere were insane. Doubtless the larger part of these 
had been epileptic for a long period ; certainly no such 
proportion of epileptics in this country would be found to 
be technically insane, especially in the early stage of the 

392 



EPILEPTIC INSANITY. 393 

disorder. Indeed, epileptics are not usually thought of as 
insane, and much less certified as such to asylums, until 
they present the most unequivocal evidence, which gener- 
ally consists in marked mental deterioration, excitement, 
dementia, or the commission of some form of crime. The 
attention is almost exclusively drawn toward the physical 
phenomena which are immediately connected with the 
convulsive stage. These are so sudden, often so startling 
in character, and so overwhelming in their immediate 
effects, that they are observed by the general practitioner 
rather than the preceding or subsequent effects upon the 
mind. These latter, however, have been carefully observed 
by specialists, and epileptic insanity was one of the first of 
the etiological forms to be differentiated and described. 

Epileptics tend to become changeable and uncertain in 
their mental states ; very impressionable and impulsive ; 
at times are irascible, morose, and untruthful; at other 
times, silly and good natured, or depressed and hypochon- 
driacal. These various mental conditions may vary in all 
degrees of intensity. In many cases the subjects become 
merely harmless dements, while in others they become 
homicidal or suicidal maniacs of the most pronounced char- 
acter. Probably there exists no form of mental disorder 
which is the immediate cause of more criminal acts, and 
many of them are of the most atrocious nature. A state- 
ment recently appeared according to which an epileptic, 
while in hospital, attempted to cut the throats of twenty-four 
patients who were in the ward with him with a razor which 
he had by some means secured. This form of insanity 
therefore becomes especially important from a medico-legal 
point of view. While, doubtless, no epileptic could rightly 
be regarded as responsible for acts in any degree con- 
nected with a convulsion, yet in the early stages there may 
34 



394 LECTURES ON MENTAL DISEASES. 

exist long periods during which the subject is quite capable 
of regulating his conduct according to the standard of right 
and wrong, the intelligence and will-power are not affected, 
and some may pass through life without giving indications 
of any marked derangement or dementia.* Nevertheless, 
the large majority do sooner or later experience serious 
lesions of the mind, and many of them find their way to 
hospitals, where they are found to be among the most 
troublesome class of patients. And even that class who do 
not reach asylums generally give indications of mental 
impairment, which consists in a dulling of the normal 
keenness of mental action, a warping of the judgment, a 
clouding of the memory, and a destruction of the higher 
and the finer sensibilities. 

It was formerly customary to refer to the epileptic 
neurosis as something akin to genius. In evidence of this 
the names of epileptics who have given indications of great 



* The mere fact, therefore, that^ a person has experienced at some former 
period of life occasional epileptic attacks does not of itself furnish sufficient 
evidence of irresponsibility. A map was recently tried in one of the courts of 
Connecticut for the murder of a woman to whom he had formerly, been engaged 
to be married. It appeared in evidence that he had experienced one or two 
fits when a boy and before coming to this country. It also appeared that on 
two occasions after he Was confined in prison, he lost consciousness for one or 
two minutes. In his confession, however, he was able to state just when 
he formed the resolution to kill her, and gave as his reason that if he 
could not have her himself he was determined no one else should. As he 
described what he did after taking his resolution, to accomplish it, his going 
to the house in the night, climbing on some lattice-work upon the roof of an 
ell of the house, his creeping carefully to the window and removing a screen 
which was in it (the weather being warm), how he entered the room and, 
finding her asleep, struck her with a sharp knife which he had for the purpose, 
and the course which he took to escapA, the court held that as his act was 
deliberate and in no way connected with or dependent upon impairment of 
mind, he must be regarded as responsible. 



EPILEPTIC INSANITY. 395 

mental abilities have been adduced. The Turks even now 
regard the epileptic as one inspired, and never interfere 
with his liberty. This in former periods was customary 
among the Greeks. But a moment's consideration of the 
nature of the convulsion itself, causing by its violence a par- 
tial suspension of the normal physiological activities of the 
brain, points to the fact that if an epileptic gives indications 
of marked ability, he does so in spite of the neurosis, and 
not in consequence of it. It is certainly impossible to con- 
jecture how a frequently recurring venous congestion of 
the vessels of the brain, with its resulting poison to the 
delicate tissue of the grey matter, could exist without 
serious modifications of this structure. Add to this, the 
spasm of the muscles of respiration and those immediately 
about the neck, of so profound a nature as to stop respira- 
tion and impede the circulation of the brain, thus producing 
extravasations of small quantities of blood or serum, with 
subsequent stupor, coma, and rigidity, and the surprise is 
rather that there should no sooner occur marked mental 
derangements. 

It would seem, therefore, to be both reasonable, and in 
accordance with medical science, to assume that no epi- 
leptic, whose disease is of cerebral origin, should be 
executed, even if he has experienced during a considerable 
period attacks of the Petit Mai only. The repeated 
changes in brain activities, attended with loss of con- 
sciousness ; sudden and dangerous impulses, hallucina- 
tions, and delusions, and such lines of conduct as cannot 
be predicated beforehand in any case from the previous 
character, and which may be traced in such persons, 
rather indicate seclusion in some hospital with medical 
treatment, than infliction of punishment as upon a criminal. 

Why a stimulation applied, either directly or indirectly, 



396 LECTURES ON MENTAL DISEASES. 

to certain regions of the motor sections of the cerebral 
cortex and the medulla oblongata should eventuate so 
diversely in different cases, in the character of the mental 
symptoms, is not quite clear, but it is probably due, in the 
first instance, to the differing degrees of susceptibility of 
brain tissue, or hereditary tendency, the degree of spasm 
and consequent congestion, and possibly to the sectional 
areas of the cortex which may be affected. 

Symptoms. — Among the many remarkable phenomena 
connected with epilepsy one of the most interesting, from a 
psychical point of view, is the aura epileptica. It is not 
always present, or, if so, not sufficiently definite in its mani- 
festations to be recognized by the subject. It is, however, 
generally present in more than one-half of the cases ob- 
served, and may indicate its presence in various ways. One 
of the most common is that of a sensation as of the blow- 
ing of the wind, or of the warm breath of another person, 
upon some localized area of the skin, or there may be a 
slightly painful sensation commencing in one of the toes or 
fingers, passing up the limb and the body, until it reaches 
the head, when the subject, who has been conscious during 
the very short time in which the movement of sensation 
has been transpiring, suddenly loses consciousness and falls 
to the ground. Then commence the usual convulsive 
movements which attend, or rather which largely consti- 
tute, the fit. The subject may be able to call out when the 
aura commences that it is coming and appeal for help, or 
he may run around the room or across the street seeking 
it. The abnormal sensation may commence on almost any 
part of the body, face, or neck, and sometimes in the stom- 
ach or bowels, in which case' it causes vomiting, but in 
whatever locality it may arise the subject is conscious of a 
sensation of movement toward the brain. 



EPILEPTIC INSANITY. 397 

There may be some unusual sensitiveness of the locality, 
but more often there is nothing unusual, though cases are 
reported in which the subsequent convulsive movements 
have been averted by applying chloroform or camphor to the 
spot when it has been definitely located. In many cases, espe- 
cially during the early stages of the disorder, the aura may 
end in merely a temporary partial unconsciousness, and the 
subjects again resume work, being hardly aware that any- 
thing unusual has occurred, or they may repeat some 
formula of words, all the while laughing. 

It is remarkable that persons do not appear at the time 
nor subsequently to have fears of being injured while pass- 
ing through these experiences. Trousseau tells of a car- 
penter in whom the aura passed into excited and rapid 
movements from one place to another. When he was 
attacked he would run over the lumber and shout for a few 
seconds, and then resume giving orders to his workmen as 
if nothing unusual had occurred. He was never deterred 
from going on to high buildings and into other exposed 
and dangerous situations, as he must have been had he 
been entirely aware of the danger to which he was exposing 
himself, but, curiously enough, he had never experienced 
the aura while in the more exposed situations. The neces- 
sity existing for alertness and concentration of attention 
doubtless stimulated the inhibitory centres of the brain, 
and this served to avert an attack. 

This sensorial derangement may be converted into 
a hallucination of any of the special organs of sense. 
Such a case was in the Retreat a few years since. He 
stated his experience to me very clearly, after his admission, 
as follows : One night, a few days before, and when his 
wife was absent from home, while sleeping he suddenly 
became conscious, and, on opening his eyes, he distinctly 



39§ LECTURES ON MENTAL DISEASES. 

saw the face of one of his neighbors, with whom he had 
formerly some unsatisfactory business relations, and who, 
he said, did not sustain a very good character, looking at 
him from behind a rocking-chair, which was standing at 
some distance from him in the bed-room. He said that he 
saw the face with as much distinctness as he ever saw any- 
thing, and at once concluded that the man was there for 
the purpose of robbing him. He jumped from the bed and 
stepped to a shelf near by, seized a revolver, shot at the 
individual, and then went to examine to see whether he 
had killed him. When he found nothing he concluded 
that he had seen a vision, and returned to his bed, but did 
not sleep any more during the remainder of the night. 
Dr. Hammond mentions the case of a lady patient of his 
in whom the period of unconsciousness was invariably ush- 
ered in by the appearance of a white cat coming into the 
room toward her. In other cases the optic and the audi- 
tory nerves become excited, and persons perceive luminous 
bodies floating in the air above them, or golden cities with 
shining gates of pearl and walls of jasper and amethyst, and 
all manner of precious stones. Again, they hear the sing- 
ing of the heavenly hosts. One of my patients used to 
insist that, at times in the night, he heard the singing of the 
redeemed in Heaven, and on other occasions he could, with 
equal distinctness, hear the groans of the lost in Hades. 

Swedenborg evidently experienced hallucinations of gen- 
eral sensations like an aura. He writes : " I was astonished, 
having all my wits about me and being perfectly conscious. 
The darkness attained its height and then passed away. 
I now saw a man standing in the corner of the cham- 
ber. As I thought myself entirely alone, I was much 
frightened when he said to me: ■ Eat not so much.' My 
sight again became dim, but when I recovered I found 



EPILEPTIC INSANITY. 399 

myself alone in the room." On another occasion he says: 
" I went to bed. * * * Half an hour after I heard a trem- 
bling noise under my head. I thought it was the tempter 
going away. Immediately a violent trembling came over 
me from head to foot, with a great noise. This happened 
several times. I felt something holy over me. I then fell 
asleep, and at about twelve, one, or two o'clock the trem- 
bling and noise were repeated indescribably. I was pros- 
trate on my face, and at that moment I became wide awake 
and perceived that I was thrown down, and wondered what 
was the meaning. I spoke as if awake, but felt that these 
words were put into my mouth," etc., etc., etc. 

I was recently consulted by a young man in whom the 
aura appeared to affect both general sensation and those 
of sight and hearing.* He said that for several months he 
had at times been aroused in the night by the sensation of 
something being blown upon his face. It appeared to him 
that it was chloroform and that it came from the transom 
over his bedroom door. He had been so much disturbed 
and annoyed by this that he had changed the location of 
his bed in the chamber, and also had hung a screen to ward 
off the effects which he was confident were produced by 
some person outside his door, for the purpose of rendering 
him unconscious. He said that after the process of blowing 
had continued for some time, he could hear the footsteps 
of some one coming along the hallway outside and passing 
to another door as if to try to open it. At other times he 
could hear somebody at the window endeavoring to come 
in. He said that it appeared to him as if the phenomena 
lasted for an hour or two, and then it would end by the 
party outside making some sudden noise, like " Oh, yes ; oh, 

* Case referred to at length on page 102 et seq. 



400 LECTURES ON MENTAL DISEASES. 

yes," or " Get out! Get out!" and all would be quiet, and 
he generally repeated the words over in a loud tone to let 
the party understand the situation inside the chamber. He 
said that he would then find himself bathed in perspiration 
from the effects of the terrible strain through which he had 
passed while he was being suffocated for the purpose of 
robbery. He could, however, immediately turn over on 
his other side, and soon go to sleep for the rest of the night, 
and generally felt well the next day. These experiences 
became so much of a reality to him that he procured a 
pistol, which he kept under his pillow each night. His 
suspicions centred upon persons residing in the house, 
and he consulted a lawyer about bringing a suit against 
them. This led to advising him to consult his physician, 
who brought him to me. In this case there existed hallu- 
cinations of general sensation, smell, and hearing, and on at 
least two occasions hallucinations of sight, as he explained 
to me that he distinctly saw upon awaking the room lighted 
up. The aura in this case did not probably pass on to the 
development of the convulsive stage, nor did he become 
wholly unconscious as far as he was aware, and it is quite 
certain that the duration of his peculiar experience did not 
continue long, if it did more than a few seconds. 

Dr. Wilkes * relates the case of a man who about two 
years before experiencing any fits " distinctly saw a number 
of soldiers with rifles, commanded by officers, drawn up to 
execute him. He could hear their voices and distinguish 
the details of their dress. This continued about an hour 
before he became unconscious." On several occasions after 
the patient Began to experience fully developed attacks of 
epilepsy he had precisely the same character of hallucina- 

*" Diseases of the Nervous System," by Samuel Wilkes, m. d., f. r. c. 



EPILEPTIC INSANITY. 4OI 

tions affecting the sight. Subsequently the aura passed 
into a disturbance of the motor system, which would con- 
tinue for some time after the loss of consciousness before 
lie fell down. 

In some cases the subjects become depressed and very 
irritable for two or three days before an attack. Such a 
patient has been under my care for several years. By the 
use of the bromide treatment fits may be prevented, but 
after a time she becomes exceedingly irritable and difficult 
to manage. Bv discontinuing the medicine for a short 
time she experiences a sudden explosion of nervous 
energy, becomes greatly excited and pugnacious, and 
then passes into a fit. She often has several with but a 
short interval between them, and then without any pre- 
ceding aura. In other cases patients may become excit- 
able, loquacious, and happy, or simply dull, with a loss of 
memory during a short period before experiencing a fit. 

Again, patients may become unconscious and not fall 
or pass into the convulsive stage, but remain in a condi- 
tion similar to that of a somnambulist. They walk about 
the room where they may chance to be with eyes open but 
apparently without sight. A female patient was in the Re- 
treat for several years, in whom this peculiar manifestation of 
the initiatory element of a convulsion never appeared until 
after a trial of treatment with the biborate of soda. This 
drug certainly greatly modified the character of the dis- 
order. She had very few fits, but in the place of them she 
experienced the tendency to walk about the hall in an 
unconscious condition. She never could recall anything 
that she had seen or done during the continuance of this 
peculiar stage, but used afterward to express some anxiety 
lest she should have annoyed others. During the continu- 
ance of the walking there appears to be enough automatic 



402 LECTURES ON MENTAL DISEASES. 

action of the spinal cord to develop locomotion, and yet 
not enough to rouse the cortex of the brain into such a 
state of activity as seems to be essential to consciousness. 

In other cases still the aura is not succeeded by the 
convulsive attack which constitutes the fit, but instead the 
subject becomes intensely excited before, and while 
passing into a condition of unconsciousness, and also 
homicidal. A case is reported by Maudsley * of a person 
who while in the fields, seeing another asleep, was suddenly 
overwhelmed with an impulse to destroy him. He seized 
a stone and, dashing it against the head of the sleeper, 
killed him at once. He then fell down beside him in a 
stupor, where he remained until found by some one pass- 
ing:. He was afterward brought to trial and found to be 
a confirmed epileptic. He was sent to an asylum, and after 
having nearly succeeded in killing an officer or attendant 
while there, finally escaped and was never found. Another 
case is reported by Marc, that of a shoemaker, who while 
at work in his shop saw one of his children, a girl often or 
twelve years of age, come in, and he immediately seized a 
knife and began to cut at her neck. He afterward declared 
that he had no recollection beyond seeing the child come 
into the room. Then "it rose into the air like the strong 
smell of marjoram. It passed through the room and over 
my head like the rays of light." 

The peculiar characters of the epileptic delirium after 
consciousness is lost assumes two principal forms, which 
have been characterized by Falret as the " Petit Mai " and 
the «« Grand Mai." 

The first of these is attended with more or less confusion 
of mind, in which consciousness may or may not be wholly 

*" Responsibility in Mental Diseases," page 16S. 



EPILEPTIC INSANITY. 403 

lost. The mind is in a condition of partial activity, and the 
innate tendencies of the individual suddenly rise into 
activity. Whatever of bad or good impulses have hitherto 
been predominant in the course of life, now become im- 
perative in action, while the subjects find it quite impossible 
to fix the attention upon anything definite. They sometimes 
become violent, or, what is more common, repeat over some 
words or sentences. There is a patient in the Retreat, at 
the time of this writing, who generally attends the chapel 
exercises regularly and has never during several years ex- 
perienced while in the chapel a grand mal. She, however, 
not unfrequently has a petit mal, the symptoms of which 
consist mainly in a slight turning of the head to one side 
and a repetition of a few words. These words generally 
consist of a declaration that she will or will not do this 
or that, and generally the thing which she will or will 
not do is something about which she has been possibly a 
little excited before coming into the chapel. 

Cases are reported in which, after the loss of consciousness, 
the subjects have, when in a semi-dazed condition, set fire to 
buildings or have appropriated articles belonging to other 
persons. M. Legrand du Saulle reports that one of his 
patients, during several times a year, experienced an aura 
which began in the stomach and passed to the head, after 
which he lost consciousness. When regaining it, he gener- 
ally found himself in jail or in prison, and with a consider- 
able number of articles about him of which he could give no 
account and which belonged to other persons. 

Other subjects become dominated with the delusion that 
they are surrounded by enemies who are seeking to injure 
them. They hear voices commanding them to perform 
some special act, and under the control of such hallucina- 
tions may burn buildings, commit homicide or suicide. 



4O4 LECTURES ON MENTAL DISEASES. 

These impulsions are generally characterized by details of 
actions which are of a very horrible and revolting char- 
acter. 

The petit mal may occur in subjects of any age, but is 
more common in young persons, or in those who have 
for many years been subject to epilepsy. It may exist 
alone or in conjunction with the grand mal. In the latter 
case, there is no regularity of succession in the two forms. 
The form likely to occur cannot be foretold with certainty, 
though the petit mal more generally follows the occurrence 
of one or several attacks of the grand mal. 

It has already been stated that the aura is not always 
present in epileptic attacks. This is generally the case in 
attacks of grand mal, which are especially characterized 
by suddenness of occurrence. The subject is not fore- 
warned, but immediately passes into a stage of convulsion 
and falls, or he may become unconscious without falling. 
These attacks are also quite alike in their general features 
in each case, differing in this respect from the petit mal, in 
which no two consecutive attacks are often quite alike. In 
the case of grand mal, therefore, the attendant knows what 
to expect, and generally can anticipate with some precision 
the degree of intensity likely to develop, and what particu- 
lar muscles and parts of the system will be convulsed, and 
with a considerable degree of accuracy how long the convul- 
sive movements are likely to continue. The sequelae in the 
way of mental symptoms may also be anticipated more per- 
fectly. If they had been those of violence or dangerous fury 
in one or two of the last convulsions, it is very likely to be 
so afterward, and preparations must be made accordingly. 
The muscular excitement rarely continues longer than a few 
minutes and generally ceases quite suddenly, though con- 
sciousness does not immediately return. 



EPILEPTIC INSANITY. 405 

Passing over now without further detail the characteristic 
physical conditions which are present during the convul- 
sive stage, and which will be found fully described in all 
systematic treatises on diseases of the nervous system, we 
come to observe the mental states which immediately suc- 
ceed the fit. These may present any one of several char- 
acters, but in nearly all cases there results a more or less 
marked derangement of the intellect. Generally there 
is present a slower mental action than is normal to the in- 
dividual. The brain is in a condition of torpor, and the 
ideas which arise into consciousness are in a confused and 
half formed condition. Replies to questions come slowly 
and words are imperfectly enunciated. The answer may 
be correct, and indicate that the inquiry has reached the 
intellectual centres, and has been interpreted with more or 
less accuracy, and yet that it has failed to rouse the mind 
into a full state of consciousness. This dull and semi-ap- 
preciative condition may continue for a few hours only, or 
remain for several days. The period of time appears to 
bear some relation, in duration, to the severity of the attack. 
During the early period of this condition of mental hebetude, 
the patient lies with eyes closed, giving no attention to 
inquiries addressed to him, and yet may be frequently 
repeating over some words or the name of some person, 
while in other cases there may be no indications whatever 
of brain activity. 

Again, instead of this condition of partial mental activity, 
there may suddenly appear what has been termed the 
" epileptic fury." The patient displays the greatest de- 
structive and reckless violence in his movements. He 
becomes intensely homicidal or suicidal, and strikes out in 
every direction, utterly regardless of who or what may be 
near by and likely to be injured; he may throw himself 



406 LECTURES ON MENTAL DISEASES. 

against the walls of his room or out of the window ; he 
may seize and break in pieces every article of furniture in 
his room on which he can lay hands. Persons who, in the 
ordinary conditions of the nervous system, are by no means 
powerful, when in this state become so strong as to require 
the assistance of several persons to control them. They 
are very likely to tear their own clothing and that of those 
who try to control them into shreds ; and they may soil 
their clothes, beds, or rooms, in the most disgusting and 
filthy manner. While in this state it becomes quite impos- 
sible to determine with any degree of accuracy the state of 
the pulse or the temperature of the body, but the congested 
state of the vessels of the face and the head, the full and 
staring look of the eye, indicate an increased quantity of 
blood in the vessels of the brain. 

This epileptic excitement rarely continues longer than a 
few hours, or at most a few days. The person gradually 
becomes quiet, and soon passes into his usual state of men- 
tal activity, but has little or no definite realization of what 
he has done while in the state of excitement. 



LECTURE XXII 



EPILEPTIC INSANITY (Concluded). 

Tendency Toward Dementia — Loss of Memory and Judgment — Case of 
Napoleon — Religious Emotions in Epileptics — Amorous Propensities — 
Religious Excitement — Dancing Mania — Acts of Great Violence May or 
May not be Connected with Convulsions —Two Cases — Homicidal Vio- 
lence — Cases — Prognosis — Pathology — Treatment. 

The general mental condition of epileptics may be 

regarded as one tending toward dementia. There have 
been, and probably are, exceptions to this rule, continuing 
for a long time. In cases where the convulsions occur but 
rarely, and with months intervening between them, in 
consequence of the inoperative state of the exciting cause, 
the mental impairment will be very inconsiderable, and 
perhaps not observable by those most familiar with the 
subjects; but the failure in mental power manifests itself 
sooner or later and is irremediable. It is especially ob- 
servable in the faculties of perception, memory, and also 
the judgment, which depends so largely upon the first two. 
Moreover, the failure of memory relates not only to what 
has recently occurred, but extends also to those experi- 
ences which have been registered many years. These are 
recalled at first with some unusual effort, and ultimately 
seem to utterly fade from the mind, which in its ordinary 
operations is dull and apathetic. 

It has been stated that Napoleon was subject to epileptic 

407 



403 LECTURES ON MENTAL DISEASES. 

attacks during or after sexual intercourse. Caesar is 
reported to have been an epileptic. If these statements 
are true it would account for the failure of their intellectual 
faculties during the latter part of their lives and before they 
had passed into the senile period. There can be no doubt 
that Napoleon gave evidence of impairment of perception, 
rapidity of mental action, and also soundness of judgment 
during the last years of his reign, and at that period of life 
when it is common to have a higher intellectual capacity 
than at twenty-five or thirty years of age. Romberg goes 
so far as to say that many males are subject to epileptic 
attacks either during or after coitus. Esquirol also refers 
to such cases. 

Many writers have drawn attention to the fact that 
religious emotions play a large role with epileptics. 
Dr. James C. Howden, in the Journal of Mental Science for 
April, 1887, has given several very interesting cases of his 
own. Some of these persons thought they were com- 
missioned to save the world ; others that it was their mis- 
sion to kill Satan ; another that he was the Almighty ; and 
another still that at times he was Christ, and at other times 
that he was the Devil. While in the epileptic trance they 
had the experience of visions and revelations which seemed 
to come to them from Heaven. Dr. Howden states the 
case of a boy whose mother was an epileptic, who, some 
time after experiencing a fit, became subject to delusions, 
which continued for a longer or shorter period, and exhibited 
strong amorous propensities. Among other delusions he 
claimed that he was Adam ; that, of course, he could not 
recall all the particulars connected with his experience while 
living in the Garden of Eden, but that he partook of the 
forbidden fruit, and in so doing did as any one else would 
have done under the circumstances. He claimed that he 



EPILEPTIC INSANITY. 4O9 

had been in Heaven, and described the scenery there as 
being quite like that of some parts of Canada. His delu- 
sions were always those of a religious type, and often very 
extravagant. Thinks at times that he is Adam, at others 
that he is Christ, and again the Devil. He claims that 
these things have been revealed to him. 

Hecker, in referring to the dancing mania of the four- 
teenth century, says " that while dancing they neither saw 
nor heard, being insensible to external impressions through 
the senses, but were haunted by visions, their fancies con- 
juring up spirits whose names they shrieked out." " Others, 
during the paroxysms, saw the heavens open, and the 
Saviour enthroned with the Virgin Mary, according as the 
religious notions of the age were strangely and variously 
reflected in their imaginations. When the disease was 
completely developed the attack commenced with epileptic 
convulsions ; those affected fell to the ground senseless, 
panting and laboring for breath. They foamed at the 
mouth, and suddenly springing up began their dance amid 
strange contortions." Religious excitement and tendencies 
appear to be most frequently associated with the petit mal 
and to arise when the epilepsy has been produced by some 
shock to the moral sensibilities of the subject. It is also 
more frequently attended with hallucinations of sight and 
hearing- and in some cases with vertigo. 

Epileptics not unfrequently exhibit acts of great violence 
which are not immediately connected with convulsions 
of either form, and these acts may be the outgrowth of 
premeditation and careful planning, in consequence of 
some imaginary insult, or the denial of a request, and, again, 
from the effects of hallucinations. A marked example 
of this was the case of the epileptic who murdered the 
Superintendent of the hospital for the insane at Avignon. 



4IO LECTURES ON MENTAL DISEASES. 

The patient said that he had during several days heard 
voices, which appeared to come to him from a distance, 
telling him that " if he did not kill the physician he would 
be unhappy for the rest of his days." During the early 
part of the day he went to the workshop, and lay in wait for 
the doctor in the vicinity of his office. Not finding him as 
he expected, after waiting for some time he inquired of an 
official if the physician-in-chief had, as yet, come to the 
hospital, at the same time saying that he was ill and desired 
to see him. When informed that the doctor had already 
arrived, and was visiting in the wards, he went to the door 
of the office and stood by himself, assuming such a position 
as indicated that he was in pain. While standing thus his 
right hand was thrust under his vest. When the doctor 
arrived, he at once called his attention, asked for medical 
assistance, and when being examined, suddenly threw his 
left arm about the doctor's chest, and with his right, stabbed 
him in his breast with the blades of a large pair of scissors 
which had been fastened open by tying them firmly with a 
handkerchief. The doctor lived but a short time, and the 
patient became excited and furious. Afterward, and while 
in a condition of sufficient reason to appreciate what he had 
done to one for whom he had much affection, he experi- 
enced great grief and remorse. At other times, and while 
under the influence of homicidal impulses, he expressed 
no regret and would try to justify his act. 

Another case, quoted by Echiverria, Journal of Mental 
Science, April, 1885, illustrative of the violence of epileptics 
at times when they had not recently experienced fits, but 
in consequence of an excitable and disordered condition of 
the brain, has been related by Legrand du Saulle : " The 

28th of January, 1868, in the afternoon, the soldier K 

was committed as a lunatic to the asylum at Marseilles. 



EPILEPTIC INSANITY. 41 I 

He was an epileptic, but unknown to be so in his regiment, 
and on his admission suddenly declared that he would not 
work, threatening his keeper with his fist. On this account 
he had to be transferred to the division for agitated patients, 

where he met with another epileptic, B , relatively quiet 

and without the strait-jacket. K and B confided 

to each other their respective griefs, and decided to revolt 
against any who should endeavor to restrain them. There- 
upon they each pulled out an iron bar from the window, 
and armed, with it, started, first knocking down one of the 
keepers, and then a second who came to his companion's 
help, fiercely crushing the skulls of their cadavers. They 
then directed their steps toward the entrance of the asylum, 
brandishing their iron bars ; but finding the doors closed, 
they returned to search the pockets of the keepers for their 
keys, and with them passed out into the adjoining division, 
where they were at last disarmed, overpowered, and secured 
with the greatest danger to the officers of the asylum. 

Shortly after this horrible scene K declared himself to 

be unhappy, cried desperately, pretended that he felt 
annoyed, that he suffered from stomach-ache, and wanted 
to see his mother ; then he became again furious, uttering 
threats of death, and trying to assault his keeper who 
brought him his meals. He told the presiding magistrate 
and the Jttge d' Instruction that he had seen flames before 
his eyes; that he heard voices speaking of murder; that 
he thought they were to kill him ; that the keepers were 
truly dead, and that they would not resuscitate, as he saw 
their brains spatter on the floor. 

"As to B , he ran into a state of great prostration. 

He remembered receiving the iron bar from K , but 

did not recollect what had happened afterward, and learnt 
with the coolest indifference the death of the attendants." 



412 LECTURES ON MENTAL DISEASES. 

These cases illustrate as well as a larger number how 
suddenly, under exciting conditions of any kind, the brain 
of the epileptic may become not only violent and dangerous, 
but bereft of all power of inhibition. In the first case epi- 
"lepsy had not been suspected, and the second was entirely 
quiet, until brought into contact with, and influenced by, 
the first. In both cases consciousness of what was being 
done seemed to be entirely in abeyance. This is distinctly 
characteristic of epileptic violence, and in this respect the 
epileptic differs from other insane persons who experience 
sudden fits of impulsive violence. 

For instance, in cases of homicidal mania the patient, 
though impelled by an irresistible impulse, which comes over 
him more or less suddenly, yet does not lose his conscious- 
ness, but is quite aware of what he has done, and may be 
able afterward to describe the modus operandi of its accom- 
plishment: this is not the case with the insane epileptic; 
all is a mental blank while the act has been taking place. 

The following cases will illustrate some of the more 
distinctive and characteristic symptoms and conditions of 
epileptic insanity as well as any I can select from my notes. 

The first case is one with marked imperative conceptions, 
and with very considerable mental impairment. 

J. C. Y., age thirty-six, English ; father was intemperate, 
his mother an invalid for many years, and his sister had a 
feeble organization ; worked hard while quite young, and 
at the age of eighteen had dyspepsia, which continued 
several years. He was affected with hypochondria, was 
unduly exercised on religious matters, and a number of 
religious delusions appeared to slowly develope in his 
mind. He heard voices, and had his mind directed by them 
to objects and persons about him ; for example, while walk- 
ing in the street he would hear a voice saying, " You are,'' 



EPILEPTIC INSANITY. 413 

and immediately his eyes would rest on some sign con- 
taining the word necessary to complete the sentence, as 
"rich;" also saw words on the sidewalk, where there were 
none. He does not speak of having on these occasions 
experienced the usual sensations attending an aura. Later - 
he became so reduced as to require treatment, and was 
benefited to some extent, but his former hallucinations 
returned, and others with them. He thought he was guilty 
of the sins of others, and was annoyed by the voices in- 
distress, had gloomy thoughts, and felt as if he had no 
friends in the world. He traveled about in the hope of 
relieving his mental suffering- but without much avail. He 
continued in this general mental and physical condition 
during several months, when he began to have modified 
epileptic attacks. He took a voyage to England, but the 
passage did not apparently agree with him, and while there 
he had more severe seizures than he had had before. 

He soon returned to this country and was admitted 
for treatment. His mind became enfeebled, his appetite 
indifferent, but his bodily health did not seem greatly im- 
paired. He had frequent epileptic seizures, and in one of 
them he fell down stairs without any apparent injury. He 
continued to refer to his hallucinations of hearing; was 
capricious and changeful in wishes, likes, and dislikes; be- 
came confused and irritable and struck other patients. He 
had from two to five convulsions a day for a year, which 
were often attended with vomiting; his diet was then greatly 
restricted, and he had a less number, and even went two or 
three days without having any. After an experience of 
some time in the use of the restricted diet and medicines, 
he began to lose flesh, and continued to do so until it 
became necessary to his physical health to increase his 
food, and he gradually returned to his usual diet. During 



414 LECTURES ON MENTAL DISEASES. 

this period he had not more than one-fourth the number 
of seizures he had formerly, but he was irritable and often 
in trouble with his attendants or fellow patients, and used 
to make frequent assaults upon them. After he resumed 
the use of an increased amount of food, the epileptic seiz- 
ures increased; his mind at this time is becoming more 
feeble, and all hope of a permanently better mental condition 
has been abandoned. 

Case. — E. R., age twenty-three, single, has a common- 
school education and resembles her father both mentally 
and physically. There are no other cases of epilepsy or 
insanity in the family, but she has a sister who formerly 
had chorea. Patient has a nervous temperament, was 
studious, fond of books and school, and had a mild and 
tractable disposition before the advent of epilepsy. The 
convulsive attacks began at the age of thirteen ; at first 
just before the first menstrual period, but since without any 
periodicity. She has become more petulant and irritable, 
and of late the convulsions have become more frequent. 
The physical health is now impaired and the mind much 
enfeebled. She has shown violent impulses, throwing 
articles at others when irritated, but has never attempted 
suicide or self injury. Generally she is careful and tidy in 
her personal habits. Of late she has become more feeble, 
is emaciated, voice is hesitating and jerky, hands are cold, 
appetite poor, digestion weak, and she does not sleep well. 
She has no paralysis and no fixed delusions, but at one 
time thought her hands were on wrong. 

When this patient was admitted there was nothing pecu- 
liar about her case. The convulsions rather increased in 
frequency, while the mental condition suffered progressive 
deterioration. About two years ago a new feature was 
developed. On the approach of a convulsion there seemed 



EPILEPTIC INSANITY. 415 

to be a gradual loss of consciousness ; the patient, uttering 
a scream and springing forward, would run down the 
corridor at the height of her speed, pursuing an erratic 
course, colliding with obstacles, and finally pitching for- 
ward, would strike her head violently against the floor, the 
furniture, or the wall. This has resulted in many severe 
cuts and bruises. About six months since the attacks 
resumed the former character of epileptic seizures. The 
patient is now in a state of almost complete dementia. 

In the above case the epileptic attacks commenced at 
the pubescent period of life, and it will be observed that 
the form of mental disturbance is in some respects like that 
which arises in pubescent insanity. There was no very 
marked excitement at any one time ; but, on the contrary, 
a condition of mental activity bordering upon stupor, which 
continued during considerably long periods. The most of 
the excitement was for a short period prior to a seizure, 
and then she was rather irritable and petulant, then 
excited. Indications of marked dementia appeared much 
earlier than in cases where the epilepsy begins at a later 
age. 

Prognosis. — This will depend, as in some other forms of in- 
sanity, upon several factors, the chief of which are the degree 
of inherited tendency and the length of time during which 
the disorder has existed. Statistics indicate recoveries in 
about twenty per cent, of those admitted to asylums. These 
recoveries are more likely to be of short duration than 
those from some other forms of insanity, inasmuch as the 
cause is rarely permanently removed. The return of the 
patient to his home is generally attended not only with an 
irregularity, or a total discontinuance of the use of the 
medicine, but also with such conditions of living as are quite 
certain to produce irritation, disappointments, and conse- 



4l6 LECTURES ON MENTAL DISEASES. 

quent excitement of the brain, which soon induce a return 
of the fits and mental derangement. Such a case is in the 
Retreat at the time of this writing. He has been a patient 
on two former occasions, and his residence at the Retreat has 
not extended during either of them beyond thre.e months. 
He has been treated with medicine regularly administered 
and has followed a regular system in the daily details of life, 
the favorable effects of which became apparent in a short time. 
When he returns to his home and family all this is reversed ; 
his medicine is neglected, friction in his employment occurs, 
and the brain soon resumes its morbid habit of activity. 
Such experiences often occur in patients who have tem- 
porarily recovered from the mental derangement of epileptic 
insanity. 

Pathology. — Authorities are generally agreed that the 
pathology of epilepsy is not yet fully understood. The 
same statement may be made in relation to that of 
epileptic insanity. Nor is it clear why in some cases 
either form of the convulsive stage should develop marked 
mental disorder, while in others no such results follow, at 
least for a long period. It is, however, quite certain that 
during the early stages of the disorder no distinctive 
pathological changes have been found by post-mortem 
examinations which would account for insanity. If any 
causal indications aside from the results of injuries, tumors, 
etc., are noticed they generally pertain to an abnormal con- 
formation of the skull and the face. Again, it is true that 
after the disorder has existed for'several years there occurs 
dilatation of the blood-vessels, together with hypertrophy 
and induration of certain portions of the cerebrum, more 
especially in the connective tissue. These conditions, how- 
ever, are more commonly found after the experience of the 
grand mal. It is in this form that the repeated pressure 



EPILEPTIC INSANITY. 417 

of the blood-vessels, and the large quantity of blood so 
long contained in the brain, produce serious effects upon 
the brain tissue, and also upon the mind, often ending in 
dementia. 

Dr. Crichton Browne, in giving the results of 64 post- 
mortem examinations at the West Riding Asylum, says 
it was found that the skull frequently becomes thickened, 
and when it is removed the brain expands, as if relieved 
from pressure, and feels hard and dense when incised. He 
found that the specific gravity was also greater than that 
pertaining to the brain in other forms of insanity. The 
convolutions were flattened, and the sulci had nearly 
disappeared. 

In cases of very long standing, and especially in those in 
which the subjects have become demented, there is gene- 
rally found a marked degeneration of the nerve cells and a 
diminution of their number ; the convolutions are dimin- 
ished in size and the whole brain is atrophied. In some 
cases there are found adhesions of the pia mater to the 
eminences of the convolutions, indicating, as in general 
paresis, former inflammatory processes. As injuries of the 
brain are among the more frequent causes of epilepsy when 
occurring in youth, we not unfrequently find the indications 
of such injuries in the form of spiculae of bone, or tumors, 
or degeneration of tissue of different forms, both in the 
grey and the white substance. 

Treatment. — The treatment of epileptic insanity is that 
of epilepsy, plus regularity of daily life, and the element of 
moral management. The treatment of epilepsy itself is 
still certainly largely empirical. It is true that by the free 
use of certain drugs the fits may, in many cases, be greatly 
modified in character and lessened in frequency, but why 
36 



41 8 LECTURES ON MENTAL DISEASES. 

such results follow the exhibition of the drugs we are 
wholly in the dark. Sometimes a change in diet, or the 
disuse of certain articles of food, or the diminution of the 
amount taken, will be followed by a lessening of the num- 
ber of the fits, while in other cases no such results follow, 
and an opposite course of a more abundant diet will act 
favorably. Similar remarks can be made in reference to 
the use of mineral tonics, several of which were in high 
estimation several years ago. I have most certainly seen 
favorable results follow the use of zinc, which was very 
frequently prescribed in past years. Nux vomica, arsenic, 
and iron are all of service in an anaemic state of the sys- 
tem, whether attended with epilepsy or not, and they are 
often indicated in epileptic insanity. 

Since 1857, however, the medical treatment of epilepsy 
has consisted largely of the use of bromide of potassium, 
and its allied salts, which have been regarded almost as 
a specific. In that year Sir C. Locock first brought the 
use of this 'drug in epilepsy to the attention of the profes- 
sion in Great Britain. Its prescription very soon became 
general, and though it has never proved all that its early 
advocates hoped and claimed for it, yet it has proved to be 
of vastly greater service in lessening the number of fits, 
and also in modifying their character, than any or all other 
drugs together. During many years I have been in the 
habit of combining it, when it is desirable to continue its 
use for considerable periods, with the bromides of sodium 
and ammonium, and also in some cases with zinc and iron. 
The depressing effects of the continued use of the bromide 
of potassium may be largely averted by its combination 
with these other salts, and when zinc or iron is used with 
them very little unfavorable effect will result. I now 



EPILEPTIC INSANITY. 4I9 

have two cases under treatment which have used these 
remedies several months without unfavorable physical 
effects and have been entirely relieved of fits. 

It should be borne in mind, however, that it is not desir- 
able in all cases to stop the fits entirely. Some patients 
complain of feeling very uncomfortable when a considerable 
period has passed without their occurrence, and say that 
they are relieved for a time after one has occurred. I now 
have a patient, who, although too much demented to under- 
stand, and much less to express, her disagreeable sensations, 
yet always becomes greatly irritable, unhappy, quarrelsome, 
and impulsive when a certain period has passed without 
the occurrence of a fit. The medicine is then discontinued 
until she has had two or three, and then is resumed again. 
By this means both the patient herself and the attendants 
are relieved of much suffering, annoyance, and care. 

By the use of this combination of the bromides, many 
cases, in which the cause is not of an organic or an in- 
herited character, may remain well during long periods, 
and some for life. The fits, however, may recur after the 
absence of many years, and consequently it is not safe to 
be too positive of a cure. I am confident that the use of 
the bromide of potassium alone in large doses tends to 
produce a weakening of the nervous system and also of the 
mind, and that it should never be recommended. As I 
have already intimated, these effects may easily be avoided 
by additional drugs and food. 

The importance of regularity in the daily habits of life, 
in the use of food, and of sleep, cannot be over-estimated. 
The same may be said of the moral management of these 
patients. The largest care should be exercised in avoiding 
all causes of excitement. Patients are so sensitive to their 



420 LECTURES ON MENTAL DISEASES. 

environments, and are so readily affected by all untoward 
influences coming from any source, that they require special 
attendance at all times by those who have the requisite 
training and skill. This is especially important before and 
after the occurrence of fits. 

The great success which has attended surgical operations 
of the brain in recent years, in consequence of after-treat- 
ment by the aseptic method, renders it probable that 
cases of epilepsy may be relieved by such measures, when 
arising from some forms of organic growths, the pressure 
of foreign substances, depressed bone, etc., and asymmetri- 
cal developments of the skull. Many cases with favorable 
results have already been reported. 



LECTURE XXIII. 



ALCOHOLIC INSANITY. 

Physiological Effects of Alcohol — Modification of — Per Cent, of Alcoholic 
Insanity — Statistics — Acute Alcoholic Insanity — .Symptoms — Illusions — 
Hallucinations — Attention — Temperature — Termination — Examples — 
Treatment — Chronic Alcoholic Insanity — Symptoms — Irritability — In- 
somnia — Loss of Memory — Paresis of Muscular System — Suspicion — 
Hallucinations — Cramps — Hyperesthesia — Gastritis — Epileptiform Seiz- 
ures^ — Delusions — Examples — Pathological Anatomy. 

Physiological Action of Alcohol. — The physiological 
effects of the continued use of alcohol upon the human 
system are doubtless of the same general character in all 
cases. It becomes rapidly absorbed into the circulation, 
and by it is carried at once to those portions of the brain 
which are more especially concerned in the processes of 
thought. It speedily acts upon the vaso-motor system of 
nerves, and thus indirectly stimulates the action of the 
heart. Its influence is also communicated to the capillary 
vessels of the grey substance of the brain, causing a dila- 
tation, and when its use is long continued a consequent 
exudation upon the delicate membranes and into the inter- 
stitial tissues. It indirectly excites to abnormal activity the 
nerve cells of the cortex and thus increases mental function. 
This increase of function is succeeded by a corresponding 
diminution after a longer or shorter period, accompanied by 
a lessening of the temperature of the whole body. 

421 



422 LECTURES ON MENTAL DISEASES. 

Modification of its Effects. — The effects of alcohol 
vary in some degree in different cases, and are more pro- 
nounced and permanent in some persons than in others. 
Not unfrequently a small quantity when used by a person 
of a sensitive and sanguine temperament, especially if accus- 
tomed to a sedentary life, has a much more profound effect 
than a larger amount used by one of lymphatic tempera- 
ment who leads a life requiring him to be much in the open 
air. Persons inheriting any of the neuroses are much 
more susceptible to its influence, which may manifest itself 
in an impairment of the moral and intellectual faculties, 
and in the development of a craving which may remain 
through life. 

The effects of alcohol, when taken in the form of beer 
or some of the lighter wines, are much less pronounced 
than those resulting from the daily use of whisky or 
brandy. In the one case it is combined with certain 
materials of which the physiological action upon the 
stomach may be highly favorable, and may aid in the more 
speedy elimination of the alcohol from the system, while, in 
the other, the effects upon the vaso-motor nerves are more 
direct, and remain for a longer period upon the elements 
of the nervous system. 

Some combinations of alcohol also affect the system more 
unfavorably than others, those rich in carbon and hydrogen 
having the least toxic effect. Persons before the age of 
twenty, and while the brain is more sensitive to unfavorable 
influences, and has less of inhibitory power, are more 
largely affected than those in later life ; a special diathesis 
may become established which renders all successful effort 
to reform much more difficult, and in the large majority of 
cases quite impracticable. In many such cases the need of 
reform is not realized, and consequently there exists no 



ALCOHOLIC INSANITY. 423 

desire for it. It is from this class that many of the dipso- 
maniacs come. 

Per Cent, of Alcoholic Insanity. — The number of cases 
of insanity which are caused by the abuse of alcohol varies 
considerably in different institutions and countries ; while 
in some the admissions which can be traced to this cause 
do not amount to more than five or six per cent, of the 
total, in others it stands as high as fifteen or twenty. In 
some countries it is thought to be affected by the facilities 
afforded for procuring alcoholic beverages. The statistics 
of American asylums indicate that from ten to twelve per 
cent, of admissions can be traced either directly or indi- 
rectly to this agent as a cause. 

At the meeting of the International Congress of Alco- 
holism in Paris, July, 1889, M. Ivernes, Chief of Statistics 
at the French Ministry of Justice, read a paper on the 
" Relations Existing Between the Increase of the Use of 
Alcohol and the Increase of Insanity and Criminality." 
From this paper it appears that " statistics very plainly 
show that there is an increase of crime in direct proportion 
to the increase of alcohol taken by each inhabitant. In 
France, from 1873 to ^87, the average annual quantity of 
alcohol taken by each inhabitant was 2.72 quarts, making a 
total increase of 29 per cent, in amount consumed. During 
this time the number of crimes and offenses increased from 
172,000 to 195,000, and the number of insane people from 
37,000 in 1872 to 52,000 in 1885, an increase of 12 per 
cent, in crime and an increase of 29 per cent, in insanity." 

" In Belgium, from 1868 to 1882, each inhabitant, on an 
average, increased the amount of alcohol used from seven 
quarts per annum up to nine quarts, thus making an in- 
crease of 28 per cent. The number of crimes and offenses 
increased, from 1868 to 1882, from 1900 for every 100,000 



424 LECTURES ON MENTAL DISEASES. 

inhabitants to 2807 ; the number of insane, which was 8240 
in 1868, has gone up to 10,020 in 1878, giving an in- 
crease of 24 per cent, of crime and an increase of 17 
per cent, of the insane." "In Italy, from 1872 to 1885, 
the alcohol consumed increased from 2.7 quarts to five 
quarts to each inhabitant, an increase of about 46 per cent. 
From 1879 to 1885 the number of criminals increased from 
1400 to 1500, and the number of the insane from 15,000 to 
22,000, an increase of 7 per cent, of crime and of 29 per 
cent, of insanity." 

The writer says : " These facts clearly show that there is 
a direct increase of crime and insanity with the increase of 
the use of alcohol ; on the other hand, an additional proof 
of the fact that a decrease of the use of alcohol in a country 
is accompanied with a corresponding decrease in the num- 
ber of crimes and insanity. In Norway, as was stated by 
M. Cauderlier in 1844, each inhabitant on an average took 
ten quarts of alcohol; in 187 1 only five quarts; in 1876 
four quarts. During the same time the criminal statistics 
came down from 249 per 100,000 inhabitants to 207 and 
180, while the number of insane patients came down in the 
same proportion." 

It is to be regretted that the portions of the above paper, 
as I have it, which refer to France and Italy do not give 
the per cent, of increase in inhabitants. The statistics are, 
therefore, so far imperfect, and we have to take the infer- 
ence of the author on his statements. 

While these statistics are too few to establish the fact 
that there exists any great and continuous uniformity 
between the use or the disuse of alcohol and the prevalence 
of insanity, yet they do tend to confirm the view that the 
use of alcohol is one of the most powerful factors in its 
causation. 



ALCOHOLIC INSANITY. 425 

We shall confine our consideration of alcoholic insanity 
to the following forms, viz. : — 

1. Acute Alcoholic Insanity. 

2. Chronic Alcoholic Insanity. 



ACUTE ALCOHOLIC INSANITY. 

The primary effect of alcohol is upon the vaso-motor 
portion of the nervous system. It acts upon this as a 
narcotic, in a degree paralyzing it, and thus removing the 
restraint it ordinarily exercises. The action of the heart 
is increased, and larger quantities of blood pass to the nerve 
cells of the brain and other portions of the system. The 
motor centres are indirectly stimulated, and the individual 
becomes more active and restless. A feeling of increased 
physical force and importance is engendered. All the 
secretions and bodily functions are more active. 

The mental faculties are also excited ; thought succeeds 
thought more rapidly ; the imagination is roused and 
speech quickened ; a general sensation of good feeling per- 
vades the brain ; the person becomes happy and joyous ; 
the recollection of matters long since past comes back with 
clearness, and the individual has a larger measure of cour- 
age and hope for all undertakings. This condition of mind 
and body, which continues for a longer or shorter period 
according to the amount of alcohol used, the susceptibility 
of the person using it, and the frequency of its repetition, 
is then succeeded by a corresponding diminution of func- 
tional activity. The power of continuous attention and 
self-control weakens ; and later the power of voluntary 
movement becomes impaired and finally abolished. The 
individual sleeps or passes into a semi-comatose state for 
several hours. In extreme cases the most automatic 



426 LECTURES ON MENTAL DISEASES. 

centres of all — those presiding over circulation and respira- 
tion — may be overwhelmed. 

The system may become in a measure tolerant of the 
presence of alcohol, and require an increased quantity to 
produce the states of excitement, but this is the case 
to only a limited extent. The repeated daily use of it, 
and its effects upon the nervous system, tend to create a 
craving for it and indulgence, until the organs of excretion 
fail to speedily remove it from the circulation, and it remains 
in contact with the elements of the brain until its toxic 
effects are fully established. The mind becomes clouded 
and its activity partially suspended ; the intellectual facul- 
ties no longer guide the purposes of the individual, and a 
condition supervenes in which no more alcohol can be 
tolerated by the stomach. Then follow the general con- 
ditions which pertain to acute alcoholic insanity, in those 
cases in which the system has become sufficiently poisoned 
by its previous experiences. 

Symptoms. — The individual becomes irritable, quarrel- 
some, and excited. The stomach becomes intolerant of 
food or drink, and rejects whatever is taken. The action 
of the heart is increased and the pulse remains continuously 
high, though small in volume and easily compressed. Head- 
ache is nearly always present in the early stage of the 
disease. The conjunctivae are injected, the pupils are fre- 
quently enlarged (though in some cases contracted), giving 
the eyes a staring expression. The patient is sensitive to 
noises, and there may exist a hypersesthesia of some por- 
tions of the body ; he is unable to sleep even under the 
effect of large doses of hypnotics. The urine is scanty at 
first, but not so later in the case. 

These general conditions may exist for twelve or twenty- 
four hours, and then the patient becomes greatly agitated 



ALCOHOLIC INSANITY. 427 

or excited, and sometimes violent. His delirium appears 
to be determined by the numerous illusions, hallucinations, 
and phantoms which are constantly floating before the mind. 
The illusions and hallucinations are nearly always of a very 
disagreeable and frightful character, rendering the person 
sad and fearful. He sees mice, rats, and snakes running 
about his room or over his person, and he is in a constant 
state of terror lest he shall be bitten by snakes or mad 
dogs. Pictures of terror appear on the walls of his room, 
and he is all the while endeavoring to escape imaginary 
enemies who are pursuing him. The hallucinations of 
sight and hearing often change with great rapidity, and in 
this respect differ from those attending other forms of 
mental disease. Both body and mind are in a state of 
agitation and excitement, and the person is unable to rest 
in or out of bed. He is in terror lest some injury or evil 
shall result from the horrible visions which are constantly 
before him. In graver cases muscular action is feeble, the 
power of coordinating the muscles of the hands and feet is 
greatly impaired, and all movements of these parts are 
attended with a trembling, which is so constant and marked 
a feature of the disorder as to suggest its name. Another 
marked feature is failure in the power of attention in relation 
to everything except the phantoms with which the mind is 
occupied. These sounds and visions are so real and terrible 
that they absorb every feeling and thought, until the body 
falls back in exhaustion or bathed in perspiration. 

The temperature generally rises one or two degrees in 
all cases in the early stage of the disorder, but as the 
patient improves recedes to the normal standard. In very 
grave cases it rises three, four, or five degrees, and if this 
temperature continues it becomes one of the most positive 
indications that there will be a fatal issue. 



428 LECTURES ON MENTAL DISEASES. 

Termination. — These general conditions may continue 
for several days, and then begin to subside; the patient 
sleeps ; the stomach tolerates food and craves it ; the hallu- 
cinations become less vivid and frequent ; the pulse lower 
and stronger ; the attention returns to actual occurrences, 
and the patient gradually passes into a state of partial 
health. In fatal cases the pulse becomes even more fre- 
quent and weak ; the temperature continues as high as 
103 or 104 F. ; the skin is constantly bathed in perspira- 
tion ; the person passes into a comatose condition, or has 
convulsions and dies. Recovery is said to rarely take place 
when the temperature remains high. 

Example ist. — E. H., age twenty-five, a bricklayer; has 
drank hard for years, but had no previous attacks. This 
one developed rather suddenly after drinking more than 
usual for several days. He was not brought to the Retreat 
at once, but was under treatment for some time at his 
room. When admitted he appeared to be weak and 
walked about with a staggering and uncertain gait ; tongue 
covered with a white coat, had no appetite, pulse soft and 
easily compressed, hands moist and cool, face covered with 
prespiration, and the muscles about the face twitching. 
Thought some one was seeking to kill him ; seemed ner- 
vous and frightened. The first night he slept very little, 
though he had taken beef-tea and chloral ; thought his 
room was full of snakes and dogs, and that the dogs were 
trying to pull him out of bed. He piled up his bedding 
in the corner of his room, in order, as he said, to cover up 
the dogs and snakes ; thought they were in his coat sleeves 
and under his vest, and would strip off both coat and vest 
in great haste and alarm, calling upon the attendants to 
help shake them out and kill them. At another time they 
were in his trowsers, cansing cramps in his legs, and again 



ALCOHOLIC INSANITY. 429 

under the cushion of the lounge on which he was reclin- 
ing, and when in the yard they were chasing him about. 

After some two weeks these hallucinations of sight and 
hearing became less vivid, his appetite became good, he 
slept longer and 'quietly, the tremors of the hands ceased, 
and he could walk without staggering. He was trans- 
ferred to another hall, where he remained until he recov- 
ered, in about four weeks from the time of admission. 

Example 2d. — J. L., age twenty-seven, single, a mechanic ; 
has been intemperate four years; first attack; had been 
drinking hard for sixty days ; was more or less irritable, vio- 
lent, and noisy for several days prior- to admission, and had 
slept but little for several nights. On admission was very 
weak ; greatly excited and restless ; the pupils were dilated, 
the conjunctivae injected ; the mouth and tongue dry, and 
the pulse increased. After going to his room, he said that 
he could see his father in the corner and on the wall with 
a glass of whisky in his hand ; soon after saw a police- 
man in the door waiting to take him away, and a crowd of 
men all around his room staring at him. After 24 hours 
he saw snakes crawling on the floor and over his bed, and 
begged the attendant to take them away ; thought he had 
been bitten by a mad dog, and exhibited his leg to the 
attendant, pointing to the wound in proof, and begged for 
whisky to allay the burning thirst in his stomach. On 
the third day, when the attendant entered his room, he 
jumped from his bed crying out, "You are going to shoot 
me," and then threw himself on the floor, shouting, " shoot 
me, for I am only a dog." Thought that they had killed his 
father and cut his mother into pieces, and that his brother 
was insane ; saw an archangel waiting for him at the door, 
and heard persons drinking at a bar in the next room ; 



43° LECTURES ON MENTAL DISEASES. 

called his attendants to look out for a lot of snakes which 
were coming, and seizing, tore up his bed-clothes to get the 
snakes out. The hallucinations of both sight and hearing 
changed rapidly from one person or thing to another ; now 
he saw some member of his family, and then it was a snake 
or angel, or a dog, but all the while he was suffering 
an agony of thirst and longing for whisky. At another 
time the boys were trying to gouge out his eyes or to cut 
off his legs. The fifth night he obtained a longer sleep 
than he had before secured, the general conditions rapidly 
improved, his tongue became moist, and he was soon ready 
to take food with relish ; the hallucinations faded away, 
and he made a good recovery. 

The prognosis is generally of a favorable character except 
in those cases which have already passed through several 
attacks, or in which the brain has become impoverished, 
shrunken, and the tissue affected by pathological changes 
hereafter to be referred to, or the person has some consti- 
tutional disorder. Of 322 cases admitted to the Blooming- 
dale Asylum, 20 died, 286 recovered, and 16 were still 
under treatment. When fatal, the issue generally occurred 
within one week (Earle). Cases, however, not unfrequently 
pass into a chronic condition. 

Treatment. — The indications of treatment are first to 
allay restlessness and excitement and to procure sleep. 
For this purpose it is important that the patient be removed 
from home and family ; that he be secluded in a darkened 
room, after a warm bath, if he is not too greatly excited or 
weakened to take one. There should be one attendant, 
and he an experienced one, and no visitors. Withdraw all 
alcoholic drinks, or if in exceptional cases any are allowed, 
it should be ale or beer, and only for a short time. A 



ALCOHOLIC INSANITY. 43 I 

warm infusion of pepper is often an excellent stimulant for 
the stomach, and will prepare it to tolerate and digest 
beef-tea. 

In the way of medicines, none operate more favorably in 
the large majority of cases in procuring sleep than the 
hydrate of chloral. If this should fail, as it sometimes does, 
the next trial of it may be preceded by opium or morphine 
combined with aromatic spirits of ammonia. The wet pack 
is highly recommended, in cases when the excitement is not 
too great, as admirable in its effects. In those cases in 
which the action of the heart is feeble, the tincture of digi- 
talis may be used as a tonic. Caution should be exercised 
as to the size of the doses employed. 



CHRONIC ALCOHOLIC INSANITY. 

Some persons may continue the use of alcohol in exces- 
sive amount for a long period and yet escape experiencing 
the conditions pertaining to acute alcoholic insanity, but 
this continued use certainly produces a profound influence 
upon the brain and nervous system, which may be followed 
by thickening of membranes, a shrinking of the volume of 
the brain, an increase of connective and fibrous tissues, and 
an exudation of fluids from the blood-vessels of the brain. 
But these conditions, or modifications of them, give rise in 
some cases to the more or less well-marked train of mental 
symptoms which attend chronic alcoholic insanity. 

Symptoms. — These generally develop slowly, and are 
preceded by certain changes in the mental character of the 
individual, such as a loss of moral tone ; a degeneration of 
the higher and finer qualities of mind ; a loss of affection 
for family and friends; a loss of interest in former pursuits 
and in care of family ; an utter inability or indisposition to 



432 LECTURES ON MENTAL DISEASES. 

heed the warnings of friends ; insomnia, irritability, and in 
some cases excitement ; a trembling of the muscles of the 
hands, a twitching of the orbicular muscles of the face, 
and a general loss of muscular power, together with an 
inability to accurately coordinate the movements of the 
hands or tongue, and a degeneration of the tissues of the 
body. 

Failure of memory is one of the most prominent of 
symptoms in many cases. It may exist to almost any ex- 
tent, from the mere loss of a word in conversation to an 
inability to recall any occurrence which took place an hour 
before. Patients are unable to recollect what food they 
have used, or whether they have used any five minutes after 
rising from the table. A patient, D. S., in the Retreat at 
the time of this writing, will repeat to me certain questions 
which are prompted by the nature of his suspicions con- 
cerning his wife as often as he meets me, notwithstanding 
the fact that I have already replied to the same questions 
ten minutes before, and have done so daily for months. He 
was formerly a broker, and yet is unable to recall a single 
date of his business life or the name of any former associ- 
ate in business. He is unable to tell whether he has been 
in the Retreat one week or one year, or to recall one 
circumstance attending his coming to it. 

Excessive suspicion is another of the marked indica- 
tions present in many cases. The patient suspects the 
chastity of his wife ; he suspects the nurse or the physician, 
and imagines that they are endeavoring to betray him to 
the authorities or to make way with him by poison ; that 
they have the police lying in wait to inveigle him from his 
home or his room, or in some other way are plotting to do 
him injury, and he endeavors to secrete a knife or a pistol 
with which to defend and avenge himself, and destroy his 



ALCOHOLIC INSANITY. 433 

imagined adversaries and his guilty wife with her paramour. 
Whatever form the subject-matter of the delusion may 
assume, he is always on the defensive and seeking to be 
ready to overwhelm his enemies and escape from their 
designs against him. 

Hallucinations are also a marked feature of the disease, 
and may exist in any of the special organs of sense. They 
may fc>e unilateral or bilateral ; seem to come from within 
or without. In one respect they differ from those existing in 
the acute form of the disease, i. e. y they are less mobile and 
changing; they may pertain to the same subject for days 
or weeks. They generally are of such a character as to 
inspire dread and fear, though to a less degree than in the 
acute form, and constitute one of the most prominent of the 
symptoms. Hallucinations of hearing are most frequent ; 
they appear to consist of voices coming from below or from 
the outside, at times indistinct, as from a long distance, and 
at other times near at hand and very distinct, accusing the 
subject of crimes and misdeeds in his past life, and threat- 
ening punishment for them. He cannot free himself from 
their presence, and they haunt him by day and night, men- 
acing him and urging him on toward some deed of violence 
or revenge. These are often united with illusions of hear- 
ing, so that sounds of almost any kind may be converted 
into cries of distress, the noise of weeping, or the calling of 
friends. Hallucinations of sight are sometimes present, 
though less frequent than those of general sensibility. 
Patients often complain of feeling a creeping sensation on 
the surfaces of their legs and arms ; of sensations like those 
arising from the blowing of air, or, again, of an electrical 
influence acting upon some portion of the body. 

Visceral and genital hallucinations are more frequently 
present in chronic alcoholism than in other forms of insan- 
37 



434 LECTURES ON MENTAL DISEASES. 

ity. One of these cases, G. P., which has been under my 
care several years, formerly experienced abnormal sensa- 
tions in the genital organs which led him to the belief that 
he had been castrated since he came to the institution, by 
means of electricity which passed through invisible wires 
in the walls of his room. During a trial which was insti- 
tuted with a view to determining his mental condition he 
informed the Judge that he had been castrated, and that 
there existed no doubt in his mind that every other male 
patient admitted to the Retreat was obliged to pass through 
a similar experience at the time of his admission. The 
character of the hallucination generally determines the form 
of the subsequent delusions. This patient, having years 
ago experienced hallucinations affecting the genital organs, 
which evidently profoundly impressed his mind, has ever 
since had a definite delusion in reference to their condition 
which has become so thoroughly ingrained in the channels 
of thought that it cannot be changed. His mental state is 
one of chronic suspicion and irritability. 

Cramps in the muscles of the legs are common, espe- 
cially at night, and the patient is often unable to sleep 
in consequence of the resultant pain which shoots up in 
the paths of the large nerves. 

Hyperesthesia of portions of the body is frequently 
present, and the patient complains of being cold, and 
requires a larger amount of clothing than when in health. 
This is undoubtedly due to a condition of instability in the 
sensory ganglia, causing sudden and irregular liberations 
and discharges of nerve energy, which may eventuate 
either in increase of excitement or sensation. Indeed, the " 
the whole nervous system is in a state of extreme instability, 
and irritations are transmitted to and from the cortex in 



ALCOHOLIC INSANITY. 435 

the most irregular manner. The temperature is generally 
lower than normal. 

The condition of chronic gastritis from which many 
patients suffer not infrequently leads them to think that they 
are being poisoned. The movement of gas in the stomach 
sometimes gives rise to the belief that there is a snake 
or some animal there. The character of the hallucinations, 
suspicions, and delusions generally renders the person sad 
and melancholic, and he may become so much depressed 
that he endeavors to commit suicide. When the element of 
suspicion is most prominent, he may become excited, and 
determine to resist and overcome his enemies, and for this 
purpose resorts to violence. 

In some cases epileptoid attacks accompanied with tremb- 
ling or twitching of the hands, faintness, difficulty in 
breathing, and sometimes with vertigo and vomiting, fol- 
lowed by great prostration, attend the course of the dis- 
order with more or less frequent regularity ; and again he 
may pass into a condition of hebetude, remaining day after 
day with a dull, stolid appearance of countenance, saying 
little or nothing to those about him, or if he replies at all 
it is only in monosyllables, or words imperfectly articu- 
lated. These mental states are subsequent to those of 
excitement referred to above, and generally are attended 
with local anaesthesias affecting the extremities and portions 
of the body. 

When the delusions and suspicions have become partially 
allayed, as is not unfrequently the case, the person will 
spend months or years in some form of daily occupation, 
under the supervision of others. He may not voluntarily 
refer to the delusions concerning his family or friends, but 
on being questioned admits that he still believes his wife 
has been faithless, and that his present condition is due to 



436 LECTURES ON MENTAL DISEASES. 

the plot of some former friend. Even when these delusions 
have entirely passed away, and the mind appears to be clear 
and active, it is rarely the case that it regains its normal 
tone. It remains permanently on a lower plane, and the 
patient becomes indifferent to the opinions of friends and 
society ; the natural affection for children and wife, and 
desire for their welfare and interests, do not resume their 
former ascendancy, and he refers to them only when ques- 
tioned. 

Example i. — J. M., age fifty, a farmer. His father died 
of phthisis. Has used alcohol, and smoked and chewed to 
excess for years. Two years ago he became morose, and 
at times subject to fits of violent anger ; was restless and 
irritable, did not sleep well, had loss of appetite, suffered 
from indigestion and lost flesh. On several occasions he 
attacked his wife and threatened to kill her, and also some 
of his neighbors, because, as he claimed, they were trying 
to get his property from him. He carried a revolver with 
him, and for some time before admission was under the 
charge of a sheriff. On admission had many ill-defined 
delusions, and was not sure of anything, but thought some 
one was plotting against him ; attributed his troubles largely 
to his second marriage, and said his enemies in town had 
concocted vile stories about him and the chastity of his wife, 
and he had left her and gone to a neighboring town to live. 
Thought he had been poisoned by wearing a pair of shoes 
which had been given him, as he had a strange sensation in 
his feet when using them. After some months he began 
to work in the garden, but persisted in his belief as to the 
chastity of his wife, and though she often wrote to him, 
said the letters were not from her. The delusions con- 
tinued active, and he made no requests to be allowed to go 
home. 



ALCOHOLIC INSANITY. 437 

Example 2. — W. A. R., a farmer, age fifty-eight; has 
been intemperate for more than twenty years ; his father 
was also intemperate. Had rheumatism several years ago, 
and has been sensitive to the effects of heat. Had partial 
paralysis of the right side seven weeks prior to admission, 
attended with loss of memory, incoherence, and delusions ; 
thought that he was not in his own house, and when in bed 
that he was walking about the neighborhood. On admis- 
sion he appeared to be weak and illy-nourished ; action of 
the heart feeble ; bowels costive ; had hemorrhoids ; loss of 
appetite ; trembling of the hands, and unsteady gait. Had 
hallucinations of sight; did not sleep; thought that the 
walls of his room were closing in on him ; was very noisy 
at times in the night from terror, at other times thought he 
was at work in the woods all night drawing wood ; or that 
he was shut up in a tomb ; complained that persons came 
into his room at night, and threw him out of bed on the 
floor; that they went to the rooms above him and shouted 
at him to prevent his sleeping ; that they were plotting to 
kill him ; thought he could see writing on the carpet of his 
room. He often complained of prickling and smarting 
sensations on his body and limbs ; also that rheumatic 
pains were present about the region of the sciatic nerves. 
These prickling pains seemed to alternate with shooting 
and electric-like flashes along his spine and the tracks of 
the spinal nerves. 

After three months the hallucinations became less vivid ; 
he slept better and was less depressed. Has, at the time 
of this writing, partial anaesthesia of his right side from his 
shoulder to his knee, and complains much of cold when 
the thermometer is at seventy degrees, and sits for hours 
with his hat and overcoat on, near the steam radiator, when 
not required to exercise in the grounds, where he walks 
daily in a feeble manner. 



43 8 LECTURES ON MENTAL DISEASES. 

Diagnosis. — This is not difficult, and may be verified by 
the history and general appearance of the person, the 
trembling of the hands, the difficulty of coordinated move- 
ments of hands and feet, the character of the hallucinations 
and suspicions, the hebetude of mind, and the change of 
character. Other points of diagnosis will be referred to in 
the next lecture. 

Treatment. — Effort should first be made to restore the 
stomach to such a condition that it will crave and digest 
food. For this purpose the vegetable tonics, preceded by 
gentle laxatives, may be advantageously used. Strychnine, 
electricity, and the acid phosphates are all of some value 
in restoring tone to the demoralized nervous system, and 
should be given in connection with abundance of food, gentle 
exercise in the open air, and, as soon as the patient is suffi- 
ciently strong, occupation in the garden and field. When 
indisposed to take exercise, or too weak to do so, passive 
exercise or massage may be employed, or the patient aided 
in exercising by attendants. Improvement may be expected, 
especially in first attacks, but relapses are very certain to 
occur, and persons rarely make good recoveries from 
chronic alcoholic insanity. 

Pathological Anatomy. — The membranes are thick- 
ened, and there are often observed slight extravasations of 
blood in the pia mater, and adhesions to the eminences of 
the convolutions, which resemble those existing in cases 
of general paresis. The volume of the brain is lessened, 
the fibrous tissues increased and the arteries atheroma- 
tous ; these vascular changes lead to partial congestions, 
softening and breaking down of the substance of the brain, 
attended with slight hemorrhages, or exudation of serum. 
The pathological changes existing in the liver, stomach, 
and other portions of the body will be found described 
in treatises on general practice. 



LECTURE XXIV. 



ALCOHOLIC INSANITY. (Concluded.) 

Alcoholic Paresis — Diagnosis of — Character of Mental and Physical Symptoms 
Contrasted — Peripheral Neuritis — Hyperesthesia — Treatment — Morphin- 
ism — " The Opium Habit " — Increase of — Mode of Invasion — Dose — 
Idiosyncrasies — Hypodermic Use of Morphine — Symptoms — Feelings of 
Exaltation Followed by Those of Depression — Increase of Dose Neces- 
sary — Loss of Memory and Moral Tone — Effects Upon Nerve Cells and 
the Sensory System of Nerves — Prognosis — Treatment. 

ALCOHOLIC PARESIS. (Alcoholic Degeneration.) 
Other cases pass into a still larger degree of alcoholic 
degeneration, and develop symptoms which closely resem- 
ble those existing in general paresis. It is important to 
observe and become somewhat familiar with any differences 
which may be found to exist in the symptomatology of 
these two forms of disease. 

I. Ideas of grandeur, an optimistic feeling, and a facile 
state of mind are often found in both these diseases. In the 
general paretic, however, they are more frequently among 
the primary mental symptoms, and, though they may be 
associated with, yet are very rarely secondary to the sensorial 
and motor disturbances. On the other hand, when exist- 
ing in alcoholic paresis they are always associated with 
motor and sensorial disorders, and are secondary to them 
in the order of their development. 

In general paretics the ideas of importance and grandeur 
are often changing from day to day, without order or con- 

439 



44° LECTURES ON MENTAL DISEASES. 

sistency. In the alcoholic paretic they are persistent, 
rarely change, and continue the same from month to month 
without any true remissions. It will also be generally 
found that there have formerly existed periods of mental 
depression, which have grown out of and been associated 
with a subacute condition of alcoholism. 

2. In both forms of disease, there exist motor and 
sensorial derangements, which appear to be of the same 
general character. A careful study of these conditions, 
however, will indicate some differences which are important 
aids in forming a diagnosis. 

The difficulty in the pronounciation of certain conson- 
ants, words, and sentences is more pronounced in general 
paresis than in chronic alcoholism. It does not become 
less except during short periods, but, on the contrary, 
increases as the disease progresses, while in chronic alco- 
holism it may disappear altogether under the influence of 
abstinence and treatment. 

The fibrillar trembling is more limited in general paresis, 
affecting mainly the tongue, orbicular muscles of the face, 
and the muscles of the hands, while in alcoholic paresis it 
affects more generally the whole muscular system. In 
general paresis the tremor and general debility march for- 
ward without remissions, or with very limited ones, in the 
progress of the disease, and the patient dies in the course 
of a few years at the longest ; while in alcoholic paresis 
there does not exist any such natural history of disease 
or systematic order of termination, but the patient may 
live on for many years. 

3. Again, in both forms of disease there may exist 
epileptiform seizures of similar character, and also local 
anaesthesias ; but associated with alcoholic paresis there 
are generally found existing hallucinations of sight and 



ALCOHOLIC INSANITY. 44 1 

more marked sensorial disorders than in general paresis. 
Derangements of the stomach also rarely exist in general 
paresis ; patients have a ravenous appetite and use large 
quantities of food ; while in alcoholic paresis the patient 
generally has gastric catarrh with loss of appetite, a loath- 
ing of food, and inability to retain it. An unfavorable 
prognosis exists in both forms of disease. 

4. Alcoholic Peripheral Neuritis. Sensory disturbances 
in the peripheral nerves are much more common in chronic 
alcoholism. They consist in an increase and disorder of 
cutaneous sensibility, as exhibited in local hyperesthesias, 
sensations of heat and cold, tinglings, pricklings, burnings, 
and cuttings as with a sharp instrument in different locali- 
ties, but generally on the arms and legs. These morbid 
sensations tend to move in the line of the nerve trunks, 
and, as the disorder progresses, to the back and up the spine. 

The increase of sensitiveness may become so extreme 
that the patient is annoyed with the weight of his clothing 
and by his ordinary motor activities, which tend to become 
more and more circumscribed. Cramps and pains are often 
present, which when relieved in one locality suddenly appear 
in another and interfere with sleep. Indeed, it is generally 
the case that sleep is imperfect and disturbed by the occur- 
rence of dreams of an unpleasant or horrible nature. 

While these anomalies of peripheral sensation are not 
strictly diagnostic of chronic alcoholism and are present in 
a modified form in some cases of primary delusional insanity, 
and also in some other disorders of the nervous system, yet 
they are rarely if ever found in cases of general paresis. 
On the other hand, local anaesthesias are very common in 
general paresis and frequently compromise extended sur- 
faces. 

While the above considerations may aid in forming a 
38 



442 LECTURES ON MENTAL DISEASES. 

diagnosis, yet it may be inferred that not unfrequently it 
will be difficult to make a satisfactory differential one be- 
tween these two forms of disease, and in some cases quite 
impracticable to do so without first becoming acquainted 
with the antecedent habits and history of the cases extending 
through a considerable period of time. There will, how- 
ever, be little difficulty in forming an assured diagnosis 
when the general paretic has advanced into the latter part 
of the second and the third stages of the disorder. 

Treatment. — As the conditions pertaining to alcoholic 
paresis depend upon and proceed from pathological changes 
in the texture of the brain which have generally been in 
process of development during a long period of time, very 
little can be done to permanently remove them. Tonics in 
the form of strychnia, iron, and phosphorus afford more 
promise in the way of ameliorating these conditions than 
other medicines. 

MORPHINISM. 

Observations. — The large and constantly increasing 
quantity of opium which is imported into the United 
States every year is an evidence, in some degree, of an 
increase of what has been termed the opium habit. The 
increasing number of persons from the middle and higher 
grades of society who seek the care and treatment of physi- 
cians, and asylums especially established for the care of such 
cases, is another indication of its growth. The effects of 
opium upon the nervous system are so deceptive, illusory, 
and soothing that the subject seems to be taken captive 
almost before he suspects a possibility of danger. In some 
respects they resemble those produced by the use of 
alcohol. Especially is this the case when the drug is used 
by persons of a highly sensitive nervous organization, or 
by those whose nervous systems have been injured during 



ALCOHOLIC INSANITY. 443 

the developmental period of life by blows on the head or 
by accidents of any kind. By the use of either of these 
articles, in process of time a craving in the system becomes 
developed, which is so powerful as to rise above and 
control the systemic activity, and largely abolish the moral 
sentiments. As this state, when produced by the use of 
alcohol, has been termed dipsomania, so, when produced 
by morphine, it may be termed morphiomania, or mor- 
phinism. 

Mode of Invasion. — In the development and growth 
of this habit, the habitual use of the two articles differs quite 
widely. In the use of alcohol it arises largely and gener- 
ally from the social customs and relations of the individual. 
Its basis may have been inherited, and the essential condi- 
tions for its growth, which only require the initiatory 
draught, or a few of them, to awaken it into full activity, 
may have existed from childhood. In other cases the pro- 
cess is much slower; but by whichever method it comes, 
the social element is always present at the door through 
which it enters. 

Now in the case of morphine this is quite the reverse. 
The habit generally has its initiation through the prescrip- 
tion of the physician. The supersensitive nervous system 
suffers from some attack of acute pain, such as neuralgia 
or sciatica, and calls aloud for relief. The compliant and 
sympathetic physician responds, as he is bound to do, 
and selects from the quiver of his medicine case the 
sharpest and surest weapon he has for dislodging the un- 
welcome tyrant of suffering. The effect is magical, and the 
subject is lifted from the realm of suffering to the seventh 
heaven of bliss. He is not only relieved from the pain, 
but elevated so far above it, and above the normal neutral 
realm of health, that he seems to be in a world of light 



444 LECTURES ON MENTAL DISEASES. 

and ecstacy. The brain acts with more than its normal 
ease and facility, the intellect is quickened, the memory 
is increased, and the imagination filled with images and 
illustrations pertaining to whatever subject may be upper- 
most in the mind for the time being. The physician goes 
his way, and thinks no more of his prescription or of his 
patient. Not so does the patient himself in reference to his 
experience. He has had sensations never to be effaced from 
his memory, and during the next and subsequent attacks of 
pain which may occur he does not wait for the dose from 
his physician ; he sends to a drug store, if he has not already 
laid in a supply of the precious substance, and prescribes it 
for himself; not once, but whenever he thinks he may require 
it, and the more frequent the prescription, the more urgent 
becomes the demand of the system for another, until the 
so-called habit becomes established ; not within a few days 
or weeks, but, in the large majority of cases, very gradually. 

The dose required to produce its physiological effects 
varies greatly in different persons. In some the system 
appears to be especially sensitive to its effects, and 
such cases are regarded as idiosyncrasies. Instances are 
reported in which one-thirty -second of a grain has produced 
a profound state of narcotism. Such persons, however, are 
in but little danger of developing " the habit." In other 
cases no such results follow even large doses. These 
differences are less marked when the drug is administered 
hypodermically than when given by the mouth ; and it is 
quite probable that this is, at least partially, accounted for 
by its not becoming fully absorbed when used by the 
stomach. The effects are also greater upon the system 
before twenty years of age than after forty or sixty. 

There exists no doubt that the danger of the formation 
of this habit is much greater from the hypodermic use of 



ALCOHOLIC INSANITY. 445 

the drug than from its administration by the mouth. This 
may arise in part from its direct and immediate absorption 
into the circulation while freed from admixture with such 
other substances as it encounters in the stomach. The 
use of morphine appears to be a vice which is peculiar to 
persons in the higher walks of life and to those who are 
engaged in sedentary and in-door occupations. It is not 
unfrequently found among members of the professions, espe- 
cially physicians, while drunkenness is more often limited 
to persons whose nervous systems are less sensitively or- 
ganized. Moreover, the opium habit is unsocial ; the indi- 
vidual uses the drug secretly and denies that he uses it at 
all, until the change in his system has become very marked, 
and necessity compels its admission. 

Symptoms. — It has already been stated that morphinism 
rarely becomes at once fully developed in the system. In- 
deed, a limited amount of the drug, say from one-tenth to 
one-fourth of a grain, may be used daily for a long period 
without the supervention of any of the well-marked con- 
ditions which arise from the use of larger doses, but 
an abnormal condition of the brain generally develops, 
especially in young persons, and nearly always one which 
requires an increased amount of the drug to satisfy the 
demand of the system. This condition is followed after a 
while by a state of mental and physical depression, which 
marks more emphatically the departure from the state 
of health, so that constantly increasing doses become 
necessary. The use of these larger doses produces a satu- 
ration of the system which eventuates in a disturbance of 
the assimilation and nutrition of the elemental tissues. 
The appetite becomes less, and the stomach less sensitive 
to hunger in .consequence of a catarrhal condition of the 
membrane. The secondary metamorphosis of tissues is also 



446 LECTURES ON MENTAL DISEASES. 

somewhat impeded, and the systemic physiological activi- 
ties are in partial stagnation and abeyance. Persons com- 
plain of more or less headache, sleeplessness, neuralgia, 
failure of the memory, and inability to apply the mind per- 
sistently to any occupation or subject of study. The 
moral sentiments become changed very early in the dis- 
order of the general system. Regard and consideration 
for friends and relatives become less marked ; the love for 
the family is lessened, the judgment clouded, and the per- 
son untrustworthy and regardless of truth ; in fact, I have 
rarely known one addicted to the practice of opium eating 
who was not an incorrigible liar. All sense of honor and 
the finer sentiments become blunted, and selfishness rules 
supreme in all questions pertaining to the indulgence of 
the habit. 

This results from the physiological effects of the drug,which 
acts directly upon the elementary tissues of the higher nerve 
centres of the brain. In consequence of the impairment of 
the nutrition of these nerve-cells, they become less sensitive 
to the normal stimulus of such impressions as reach them 
from the external world, or from the past experiences, which 
have become registered as memories. The subject becomes 
demoralized ; such ambitions and aspirations as he has 
cherished in the past seem largely to fade out, and he seeks 
for indulgence in seclusion. The effects of morphine 
upon the social faculties differ largely from those of alcohol 
in this respect. The indulgence in the latter tends rather to 
increase the love for social life, and the satisfaction appears 
to be doubled if one is in the company of his friends, or 
even with strangers. With the opium-eater this is quite 
reversed, and his indulgence is in private. The sensory 
system of nerves also becomes blunted and the muscular 
system less capable of continued activity, while an abnormal 



ALCOHOLIC INSANITY. 447 

distention of the capillary vessels of the extremities is often 
present. 

The more delicate movements of the hands and fingers 
become affected and are uncertain; the muscular fibrillae of 
the surface of the tongue, when it is extended, are in much 
the same uncertain state as when the subject has general 
paralysis. The eyes assume an habitual lustreless, vague 
expression, the face is pinched, and any considerable physi- 
cal exertion is attended with fainting or a feeling of ex- 
haustion. At times the subject is unable to sleep, and, 
when he does, is troubled with nightmares and horrible 
dreams. He, however, rarely has hallucinations or fixed 
delusions. 

The amount of morphine required by the system to 
relieve these distressing symptoms, both physical and men- 
tal, tends constantly to become greater, and in some chronic 
cases is very large. Ten grains per day is not an unusual 
amount, and several cases have been under my observation 
in which double this amount was taken at a single dose. I 
have seen one case in which a drachm a day had been used. 
In such cases the departure in the various organs of the 
system from the standard of normal activity has become 
very great ; a true neurosis has become established, or, at 
least, a habit so profound and imperative that it rules the 
whole system. Any departure from it, therefore, causes a 
commotion, attended with a suffering which is little short 
of agony. The adjustment of the tissues of the brain and 
the nervous system to the presence of the drug has become 
a sort of second nature, and the artificial condition for the 
time being is almost the physiological one. Any movement 
toward a return to a normal state, by withdrawing the nar- 
cotic, is attended with suffering so great as to be little real- 
ized by those who have not witnessed it. Moreover, when 



44-8 LECTURES ON MENTAL DISEASES. 

the system has once triumphed over the habit, and become 
free from the more immediate effects of the drug, there ever 
after exists a strong probability that its use will again be 
resumed whenever any considerable demand for physical 
exertion and hardship may become necessary, or the person 
experiences the effects of ill health. The prognosis is, 
therefore, unfavorable in all cases which have extended over 
a long period, and especially when the habit has been 
formed before twenty-five years of age. 

Treatment. — There are two methods of managing such 
patients. The first is by withholding absolutely the mor- 
phine at once. Dr. Austin Flint and other authorities 
advocate this course. The other is that of a gradual 
diminution until the doses are so small as not to be ap- 
preciated by their effect. I am in the habit of following 
the latter method. The sudden and absolute withdrawal 
of the drug, which has been used perhaps for years in large 
quantities, causes so great suffering that I prefer a gradual 
and rather rapid diminution of the quantity given. When 
this is done systematically, and with mathematical accu- 
racy, every day, the suffering is greatly lessened, and the 
danger of collapse and impulsive delirium generally avoided. 
In some cases, especially when persons are in vigorous 
health, the sudden withdrawal is the best method to pursue. 
The patient is sooner on the highway to recovery. When 
the morphine is gradually withdrawn, it is better to have 
everything conducted so that the patient shall know nothing 
as to the rapidity with which the doses are diminished. 
Larger doses are usually required at night than during the 
day, and the condition of irritation may be relieved by the 
use of chloral, alcoholic stimulants, and the use of solid 
food at night. The bromides of ammonium and sodium 



ALCOHOLIC INSANITY. 449 

are also of essential service in allaying restlessness and 
aiding to procure sleep. 

The propriety of regarding and studying morphinism as a 
form of insanity may possibly be questioned by some, but as 
its effects when carried beyond certain limits, which vary in 
individual cases, produce demoralization and a partial de- 
rangement of all the higher mental faculties, I think every 
such case should be carefully studied. No intimation is 
here intended that every person who habitually uses mor- 
phine should be regarded as technically insane or be 
considered as irresponsible. Each case must be regarded 
by itself. Not all inebriates are insane, though some are, 
and the effect of both alcohol and opium upon the nerve 
cells of the gray matter of the brain have a considerable 
degree of similarity when long continued. 



LvKCTURK XXV. 



GENERAL PARESIS. 

Synonyms — Importance — Definition — Etiology — Sex — Age — Heredity — So- 
cial Position — Locality — Statistics: I. In New England Institutions; 2. 
New York Institutions, Michigan Institutions — Comparison of the Different 
Sections, Different Nationalities, and Races — Sexual Indulgence — Table 
of Causes from Reports of the Commissioners of Lunacy in England — 
Syphilis — Intemperance in the Use of Alcohol — Acquired or Inherited 
Tendency — Symptoms: I. During the Initial Period — Maybe Those of 
Elation or Depression — Peculiarities of Mental and Physical Symptoms 
in Both These States — Duration of Initial Period. 

Synonyms. — General paralysis of the insane. Paralytic 
insanity. Paralytic dementia. General paralysis. Paretic 
dementia. Progressive general paralysis. 

The discovery and differentiation of no form of insanity 
has been attended with such important results to psychology 
as those of the disorder we are now to study. Concerning 
no form of mental disease has there been so much written 
during the past twenty-five years in Germany, France, and 
Great Britain. This has been due not only to its great 
intrinsic importance, but also in part at least to the fact that 
it is attended by, or consists in, lesions of the brain and 
other portions of the nervous system which are easily 
demonstrable. The interdependence of mind and brain 
have by this fact been more definitely and clearly shown 
than ever before. 

Some knowledge of this disease is of special importance 

450 



GENERAL PARESIS. 45 I 

to medical students and general practitioners in this country 
from the fact that it appears to be rapidly increasing, 
especially in large cities. This is doubtless due to the 
development of conditions and changes in the habits and 
practices of society as well as in the forms of our civiliza- 
tion which will hereafter be referred to and explained. Our 
progress in its study may be facilitated by presenting some 
form of definition with which to commence, and yet so 
multiform are its symptoms and so diverse are its anatom- 
ical lesions that it is not easy to formulate one in the 
compass of a few lines. I, however, suggest the following 
as sufficiently accurate for our present purpose. 

Definition. — General paresis is a disease primarily affect- 
ing the brain and nervous system ; attended by organic 
changes in the cortex and some of its membranes ; 
evidenced by mental symptoms of an expansive and ex- 
alted, or in some cases of a depressive character ; also by 
certain physical symptoms, such as paresis resulting in a 
peculiar affection of the speech, especially in the articulation 
of words ; disorders of motility, incoordination of gait, and 
generally with disorder of sensibility, and finally with 
paralysis ; the disease passing through a more or less 
definite course, ending in death within a few years after 
the appearance of characteristic symptoms. 

iEtiology. Predisposing. — I. Sex. — The statistics of 
all authorities agree in demonstrating that general paresis 
is much more prevalent among males than females. The 
degree of difference, however, varies considerably with 
different writers and in different localities. In my own sta- 
tistics, hereafter referred to, relating to New England, it is 
found that the admissions of female paralytics stand, in 
proportion to that of males, almost exactly as one to ten, 



45 2 LECTURES ON MENTAL DISEASES. 

in those relating to New York, as one to six and five-tenths, 
showing a large difference in the two localities. 

Taking the two States of Vermont and Maine, in which 
there are no large cities, and we find the proportion of 
female paralytics to male is that of one to three and five- 
tenths, thus exhibiting a difference of six and five-tenths 
per cent., as compared with the numbers which cover the 
six New England States, and the percentage of both sexes 
is also lower. Among populations residing largely in the 
conditions of country life, therefore, exciting causes appear 
to affect both sexes more nearly in the same degree than 
in centres having a large population. 

The Commissioners in Lunacy, in England, make the 
proportion of admissions four males 4:o one female. In 
Germany the ratio is much greater in public than in private 
asylums, it being nine to one in the former, and only about 
-four to one in the latter. Dr. Mickle has computed the 
admissions to asylums in England, amounting to 54,642, and 
finds that the per cent, of general paresis among males was 
12.65 an d among females 3.25, which would yield a pro- 
portion of about four to one. 

The ratio of the sexes at the Retreat, during the past 
twenty years, has been eight males to one female. 

2. Age. — This form of disease is much more common 
between the ages of thirty-five and fifty years than during an 
earlier or later period of life. Of the seventy-four cases 
which have been in the Retreat during the last twenty years, 
the youngest male was twenty and the youngest female was 
twenty-six at the time of admission. The oldest male was 
sixty-nine and the oldest female was sixty-one. The aver- 
age age of males was forty-five, and that, of females was 
forty-eight. I saw the case of a female patient in la Salpetri- 
ere, Paris, several years since, who was only eighteen ; and 



GENERAL PARESIS. 453 

cases are reported as occurring at a still earlier age. These 
extremes, however, in either direction among males or 
females, are the exceptions, and comprise but a very small 
proportion of the total number of cases. The large major- 
ity of cases, as indicated in the above average among men, 
occur in the prime of physical development, and when the 
brain and whole nervous system are in the highest state of 
functional activity and vigor. 

The above average age among female general paretics is 
at variance with general statistics, which indicate that the 
disease appears in women from three to five years earlier 
than among men, instead of three years later. Modern and 
fuller statistics tend to show that general paresis appears 
within the last ten years, in a larger proportion of cases, at 
an earlier period of life than the statements of some authors 
would seem to indicate. 

3. Heredity. — Hereditary influences have been regarded 
as one of the strongest predisposing causes of general 
paresis. We should predicate this from the character of 
the disease itself. As it appears to arise primarily in a 
hyperaemic, or subacute, inflammatory process, which af- 
fects the cerebral cortex, we certainly are warranted in 
conjecturing that persons who are leading lives attended 
with great mental excitement, reverses in fortune, and conse- 
quent strain and disappointment, will be more likely to beget 
offspring who may, under the influence of exciting causes, 
develop general paresis. Without doubt, in this manner 
heredity becomes a most important factor as a predispos- 
ing cause. Indeed, there can be as little doubt that there 
exists a general paretic dyscrasia or diathesis, as that there is 
a cancerous or a tuberculous diathesis ; and as both these 
have been evolved, in the process of time, from the influence 
of certain experiences which pertain to life in the conditions 



454 LECTURES ON MENTAL DISEASES. 

of civilization, so in like manner will a general paretic dia- 
thesis develop into a larger degree of activity, and conse- 
quent frequency of transmission, under the stimulation of 
the twentieth century civilization and the influence of 
certain diseases. 

In my own cases, hereditary influence appears to have 
existed in nineteen per cent, of males and in 22.2 per cent, 
of females, this number having had parents who had suf- 
fered from some forms of mental or brain diseases. In the 
tables of Dr. Mickle, heredity existed in 14.3 per cent, of 
males and in 19. 1 per cent, of females. 

4. Social Position. — There exists no doubt that the gen- 
eral conditions incident to life in the lower ranks of society 
predispose to some forms of mental disease, and that a higher 
per cent, of these classes than of the more wealthy become 
insane. Does the same rule hold true in the case of gen- 
eral paresis ? I have no information or general statistics 
of hospitals in this country which will shed light on this 
subject. Referring to those presented by Dr. Mickle, we 
find that out of 5454 private male patients, the per cent, ot 
general paralytics was 9.63, and in 4173 female patients 
the per cent, was 1.84. Total, 5.91 per cent, of private 
admissions. 

Of 22,113 pauper male patients, 13.38 per cent, were 
general paretics, and of 23,811 pauper female patients, 3.5 
per cent, were general paretics, yielding 8.2 1 per cent, of pau- 
per admissions. This indicates nearly four per cent, more 
of general paresis among pauper male patients than among 
private male patients, and 1.22 per cent, more of pauper 
females than of private females. 

It should, however, be borne in mind that more or less of 
those classified as pauper cases, because in public asylums, 
actually have belonged to the higher classes, or at least 



GENERAL PARESIS. 455 

did not belong to the pauper class until rendered helpless 
by disease ; and it is quite, impossible to arrive at any accu- 
rate conclusion as to this point by general statistics. There 
is no doubt that a general paretic diathesis is active and 
prevalent in this country in all classes of society, but my 
statistics indicate that it is much more prevalent among the 
poorer classes and the populations of cities. 

Of those cases that have been in the Retreat during the 
past twenty years, 58 per cent, had been engaged in occupa- 
tions requiring brain work almost exclusively, 35 per cent. 
in manual occupations, and 7 per cent, had no occupation. 

5. Locality and Race. — One of the curious facts in relation 
to general paresis is, that it has been and still is very rare 
in Ireland, Norway and Sweden. Until within a few years 
it was said not to exist in Ireland. Recent reports, how- 
ever, indicate a very small per cent, in the larger asylums 
which receive patients from cities, but the contrast as to 
numbers affected with the disease on the different sides of 
the Channel is very marked. When the Irishman emi- 
grates across this Channel, he loses his immunity and suc- 
cumbs to exciting causes ; so that it is common enough to 
find Irishmen with general paresis in England, Wales, and 
Scotland, and also in America, though in less number in 
proportion than among Anglo-Saxons. Climatic influences 
can, however, have a very small share in securing any such 
immunity, as they are quite similar in the two islands. 
Doubtless the racial element contributes a quota of influ- 
ence toward an explanation of the peculiarity, but a much 
more efficient cause exists in the contrast between the 
mental and social habits of the inhabitants of Norway and 
Ireland, and those of England and America, with their 
great cities and manufacturing centres. The whole routine 
of the daily life of the one is limited to an out-of-door exist- 



456 



LECTURES ON MENTAL DISEASES. 



ence and largely to a cultivation of the soil, with little to 
stimulate the ambition or the imagination ; while that of a 
much larger proportion of the other is mainly indoor, 
and requires long-sustained mental activity, and often con- 
tinued anxiety and excitement. 

Statistics indicate that general paresis was much more 
frequent in Central and Northern France than in Southern 
France twenty years ago. At the present time this differ- 
ence is becoming much less. Whether this change is due 
to an increase of certain habits pertaining to the social life 
of the people or to improved methods in diagnosing the 
disease is uncertain. 

The following tables of statistics will indicate to some 
extent how great has been the increase of general paresis 
in certain sections of the United States. They also enable 
us to make a comparison between the different localities 
to which they relate. The statements of numbers have 
been prepared for me by the superintendents of the asylums 
which they represent, and cover twenty years, or four quin- 
quennial periods. Those relating to New England are from 
all the public institutions for the insane with one exception. 



NEW ENGLAND ASYLUMS. 



Admissions. 


Paretics. 


Percentage. 


Males. 


Females. 


Males. 


Females. 


Males. 


Females. 


Total. 


4,123 


3,625 


137 


18 


3-32 


•49 




2. 


4,980 


4,435 


63 


25 


1.26 


•56 




o-93 


5,395 


4,866 


354 


43 


6-55 


.88 




3.86 


6,775 


6,010 


494 


125 


7.29 


2.07 




4.88 


21,273 


18,936 


1,048 


206 


4.92 


1.08 


3-II 



GENERAL PARESIS. 



457 



In the first quinquennial period, the statistics relate to 
seven asylums, in the second to ten, in the third to twelve, 
and in the fourth to thirteen, additional ones having been 
erected from time to time. 

It will be observed that the percentage of general paretics, 
during the first quinquennial period, was of males 3.32 and 
of females .49 ; total, 2.0 ; and that during the fourth quin- 
quennial period it was of males 7.29 and of females 2.07 ; 
total, 4.88, an increase of more than one hundred per cent. 
How far this increase is due to greater accuracy in diag- 
nosis is uncertain. 

The table relating to New York embraces all the public 
institutions of the State except those in the immediate 
vicinity of New York city. As these receive largely from 
the foreign element of immigration which lands in the city, 
I have not thought proper to include them in this cal- 
culation. The table for the first period contains the statistics 
for four asylums, the second for five asylums, and the third 
and the fourth those of eight. 



NEW YORK ASYLUMS. 



Admissions. 


Paretics. 




Percentage. 


Males. Females. 


Males. j Females. 


Males. 


Females. 


Total. 


1,728 I,8l6 
2,359 2,284 

3> 62 3 3, 2 33 

4,896 4,116 


138 
215 
371 
448 


22 
21 

47 
66 


7.68 
9.II 
I0.2 
9.I7 


1. 21 

.91 

1.44 

1.6 


4-44 
5.08 
6.69 
6.91 


12,606 I 11,449 


1,172 


156 


9.29 


1-36 


5-52 



These statistics relating to New York indicate a less rate 
39 



458 



LECTURES ON MENTAL DISEASES. 



of increase, giving a total of from 4.44 in first period up to 
6.91 during the last period. 



MICHIGAN ASYLUMS. 



Admissions. 


Paretics. 


Percentage. 


Males. 


Females. 


Males. 


Females. 


Males. 


Females. 


Total. 


2IO 


292 


22 


2 


IO.4 


.68 


•47 


922 


82O 


Il8 


3 


12.6 


.36 


6.94 


1,177 


926 


217 


7 


18.5 


•75 


IO.6 


1,204 


1,009 


I08 


23 


8.9 


2.2 


5-9 


3,513 


3.047 


465 


35 


I3.2 


1.1 


7.6 



In the asylums of Michigan, which is one of the newer 
States, the per cent, of general paresis increased rapidly 
during the first three quinquennial periods among males, 
and but very little among females. During the last period 
it was lower in both sexes than during the preceding one. 
How far this may have been due to a change in the char- 
acter of the increase in population there is no means of 
determining. 

The following table presents a comparison between 
the statistics relating to the three localities, by which it 
appears that the per cent, of general paresis in Michigan is 
much higher than it is in either New York or New England. 
This difference in increase cannot be explained on the 
ground of there being a higher per cent, of foreign-born 
persons in Michigan. According to the United States cen- 
sus of 1880, the population of foreign born to the native 
population was very nearly alike in both New York and 
Michigan, it being in both States 31 -f per cent., while 
in the New England States it was 22 -f- per cent. 



GENERAL PARESIS. 



459 



NEW ENGLAND, NEW YORK, AND MICHIGAN ASYLUMS, 
RESPECTIVELY. 





Admissions. 


Paretics. 


Percentage. 


Males. Females. Males. Females. 


Males. 


Females. 


Total. 


N.E. . 

N.Y. . 
Mich. . 


21,273 18,936 1,048 206 4.92 

12,606 11,449 1 I , I 7 2 j 156 1 9.29 
3,5i3 3,047 ' 465 35 13-2 


I.08 
1.36 
I.I 


3- J i 

5-52 
7-6 


T o ta l> . 37,392 1 33,43 2 2,385 [ 397 7.18 


1. 12 4.34 



By a comparison of Table 4 with that of Dr. Mickle on 
page 462, following, and with the assumption that they 
represent, with a fair probability, the per cent, of general 
paresis existing in England and the United States, we find 
that for every 100 male general paretics in England there are 
56 -J- in the United States, and for every 100 female gen- 
eral paretics in England there are 34 + m the United 
States; and for every 100 of both sexes in England there 
are 55 — j- In the United States. 

Dr. Bannister* has presented the statistics relating to race 
of 91 general paralytics admitted to the Illinois Eastern 
Hospital for the Insane as follows : Anglo-Saxon races, 47 
males and five females ; German race, 14 males and one 
female; Scandinavian races, two males and one female; 
total of Teutonic races, 63 males and seven females ; total 
of Celtic races, ten males and three females ; total of Latin 
races, two males, no females ; total Sclavonic races, one 
male, no females; Jewish, two males, no females; African, 
no males and three females ; grand total of 78 males and 



* American Journal of Insanity, 1888. 



460 LECTURES ON MENTAL DISEASES. 

13 females, making exactly six males to one female, and 
57 + per cent of the Anglo-Saxon races to 42 -f- per cent, 
of other races. Dr. Bannister says that the above patients 
come from all portions of the State, and that " the foreign 
element in its population, which amounts to more than 50 
per cent, of the whole, also comes from all parts of the 
State." 

Of my own cases, 68 were born in America, two in 
Canada, one in England, one in France, one in Germany, 
and one in Ireland. 

Exciting Causes. — As general paresis is characterized 
by a quite definite and clearly marked class of symptoms, 
and these, both physical and mental, are to a certain 
extent sui generis, this peculiarity has been thought to 
indicate some special cause, or at least that some special 
cause is in more active operation than in the production ot 
other forms of insanity; for example, excessive sexual 
indulgence. Maudsley, Shephard, and Sankey all agree 
as to the prime efficiency of this factor as an exciting 
cause, and in confirmation the latter says* that Dr. Con- 
noly told him that in his large experience he had never 
met with a case of general paresis among females in the 
upper classes of society. 

This theory possibly arose from, and certainly appears 
to be strengthened by, the fact that the disease is much 
more prevalent among the populations of large cities, where 
the conditions of life favor greater excesses in sexual 
indulgence than in regions more sparsely inhabited. It 
should, however, be remarked that the disease was much 
less frequent fifty years ago among the very classes which 
it most affects at the present time ; it may, therefore, be 

* " Lectures on Mental Diseases," H. W. A. Sankey, p. 182. 



GENERAL PARESIS. 46 1 

presumed that there are other influences in operation more 
largely than at the former period. While sexual im- 
morality has doubtless been common enough in all ages 
since the race began to live in the conditions of civiliza- 
tion, still, in view of the fact that large numbers of general 
paretics have led immoral lives, there can be no question 
that this, in connection with other exciting causes, has had 
a considerable influence in producing the disease. In the 
experience at the Retreat it was regarded as the cause in 
5.4 per cent, and was doubtless but one of many others. 
That this is a general proposition becomes apparent from 
the table (page 462), which has been prepared by Dr. Mickle* 
from the reports of the Commissioners of Lunacy in 
England. 

It is readily perceived that this etiological table is 
equally valuable in exhibiting the causes of other species 
of insanity, as that of general paresis. Indeed, the three or 
four leading factors as here presented, i.e., intemperance 
in the use of alcohol, adverse circumstances, including 
poverty, heredity, and bodily diseases, are those which 
are prominent in all etiological tables of insanity. Cases in 
which ovarian disease, religious excitement, self-abuse, 
parturition, or the puerperal state, and congenital de- 
fect have been efficient as causes must be very rare in the 
asylums of this country. Only in tables comprising very 
large numbers of cases do they appear, and then only in a 
very small per cent. 

Dr. Folsomf finds syphilis a very frequent cause ; it was 
present in two-thirds of all his cases, and Dr. Bannister has 
a similar experience. Dr. Ascher, of the Dalldorf Asylum, 



* Mickle on " General Paralysis of the Insane," p. 263. 
I Boston Medical and Surgical Journal, 1 889. 



462 LECTURES ON MENTAL DISEASES. 

Berlin, found that it had existed in 109 out of 313 cases 









Males. 
Average 


Females. 


Total 








Average 


Average 










per CENT. 


per cent. 








per cent. 




inG. P. 
Admis- 
sions, 

BOTH 


Causes. 


Males. 


Females. 


in Male 

G. P. 
Admis- 
sions. 


in 
Female 

G. P. 
Admis- 








sions 


Sexes. 


Moral. 












Domestic troubles, .... 


124 


86 


3-6 


9.4 


4.9 


Adverse circumstances, . . 


373 


44 


109 


4-8 


9.6 


Mental anxiety, 












Worry and overwork, . . . 


221 


29 


" 6.4' 


3-i 


' 5-6' 


Religious excitement, . . . 


29 


7 


.8 


•7 


.8 


Love affairs, including se- 












duction, 


15 


12 


•4 


I -3 


.6 


Fright and nervous shock, 


15 


6 


•4 


.6 


•5 


Physical. 












Intemperance in drink, . . 


795 


122 


23-5 


134 


21 4 


Sexual excess, 


80 


29 


2,3 


3-i 


2-5 


Venereal disease, .... 


41 


8 


1.2 


.8 




Self- abuse, 


10 




•3 




.2 


Over-exertion, 


46 


Y 


i-3 


W 


1.1 


Sunstroke, 


94 


3 


2.8 


■3 


2-3 


Accident or injury, .... 


256 


24 


7-5 


2.6 


6.4 


Pregnancy, 




8 




•9 


.2 


Parturition and puerperal 










state, • 




45 
15 
12 




•5 
1.6 

'•3 


.i 


Lactation, 






•3 
•25 


Utero-ovarian disease, . . 




Change of life, 




36 




•4 


.8 


Privation and starvation, . 


51 


36 


1*5 


3-9 


.2 


Old age, 


10 


9 


•25 




45 


Other bodily disease, . . . 


352 


in 


10.3 


12.2 


10.7 


Previous attacks, .... 


162 


68 


4-7 


7-4 


5-3 


Heredity, 


490 


175 


14-3 


19.1 


15-4 


Congenital defect, .... 


4 


5 


.1 


•5 


.2 


Other causes, 


38 


6 


1.1 


•7 


.1 


Unknown, 


991 


297 


29-3 


32.6 


30.0 


Fevers, . . 


12 


1 


•35 


.1 


•3 


Total, 


3374 


910 


12.65 


3-25 


7.8 



investigated by. him, equaling 34.7 per cent. He, however, 



GENERAL PARESIS. 463 

embraces cases in which, the persons had passed many 
years since infection, and during which other and very 
efficient causes may have been in operation. 

According to the same authority, intemperance in the 
use of alcohol had existed in 37.6 per cent., besides those 
cases in which it may have existed as a symptom. Fifty- 
eight * out of 643 cases had experienced injuries of the 
head. (May not the injury in some of these cases 
have been a consequence rather than a cause, the result of 
disordered processes pertaining to the vaso-motor system ?) 
Three were congenitally feeble-minded and four had had 
previous attacks of insanity. Abuse of tobacco was 
the cause in five cases and poisoning by lead in three. 
Psychical causes existed in 106 of the cases, and these were 
largely reverses in fortune, grief, anxiety, and distress, 
arising from unfortunate social relations. 

In 74 of my cases, syphilis was known to have existed 
in only three ; service in military life, two ; reverses in 
fortune, ten; intemperance in the use of alcohol, 
seventeen; sexual excess in four ; overwork and men- 
tal strain, eleven ; sunstroke, one ; ill health, four ; 
disappointment in love, two ; climacteric, one ; domes- 
tic troubles, one; epilepsy, one; injury to spine, 
two ; parturition, one ; tabes dorsalis had preceded men- 
tal symptoms several years in one case, and apoplexy in 
one. Direct heredity on father or mother's side in four- 
teen cases, and indirect in eleven. 

Back of all exciting causes, however, there must exist 
the predisposing one, either acquired or inherited, viz., that 
of a special dyscrasia or diathesis. This consists of a cere- 
bral cortex, abnormally impulsive, easily impressionable, 

* American Journal of Insanity, 1889. 



464 LECTURES ON MENTAL DISEASES. 

and over-sensitive to disturbances of the vaso-motor 
system ; consequently abnormally subject to congestions 
and resultant excitement, with defective inhibitory capacity. 
Given such a basis, and numerous exciting causes will 
prove potent in the development of the disease which would 
otherwise have been inoperative. 

Symptoms. — The mental symptoms of general paresis 
do not uniformly precede the physical. Indeed, there are 
numerous cases in which the latter in both motion and 
sensation are first in the order of appearance ; but as the 
changes in the character of mental activities, are generally 
those first noticed by both the lay and professional 
observer, and are those which call attention to the neces- 
sity of restricting the liberty of the individual, they should 
take precedence in the order of examination — the physical 
changes attending each period being presented with it. 

In a description of the symptoms we may class them 
under three more or less distinctly marked stages of the 
progress of the disease. 

First, the initial period. 

Second, the pronounced period, and 

Third, the period of decay. 

Many cases, however, occur in which these periods are 
not distinctly bounded or separated from each other, and 
the conditions which may be described as pertaining to 
any one of them may pass over into the next in order. 

Initial Period. — The affective faculties are generally the 
first to become changed in the character of their activi- 
ties. The person is observed to be unusually sensitive to 
the effects of the ordinary experiences of life. This may 
show itself either in unusual good feeling and exaltation i 
or in depression. 

If in the former it may be by the exhibition of an 






GENERAL PARESIS. 465 

unusual interest in matters which have hitherto received 
little or no attention, and in which he is not really con- 
cerned, while the duties and occupations which have been 
followed for years receive only a fitful and irregular inter- 
est. The person intimates to his companions, or to the 
members of his family, that he is about to accomplish 
something of vastly greater importance than he has ever 
done before, and at the same time he is utterly careless as 
to the necessary means by which it is to be done. At 
other times he boasts of his physical strength and of his 
ability to cover long distances in an incredibly short time ; 
again, of his importance and position in society, and 
becomes unduly familiar with persons whom he knows 
little of; he becomes easily excited, irritable, and uncertain 
in his mental states, with inability to apply the mind long 
at a time to any task. 

When work is undertaken it is done in a slovenly and 
imperfect manner, without apparently any appreciation of 
the failure by the patient himself. He goes from one thing 
to another, is changeful and irresolute, his mental state at 
any point of time is quite in contrast with what it may be 
the next hour. The irritability may at times become so 
exaggerated as to lead to abuse of wife and children, and 
to acts which border on violence. Unusual explosions of 
temper may appear at intervals for years prior to the pro- 
nounced symptoms, all of which indicates that a change 
in character has occurred, though at the time it is little 
thought of by the friends. 

In other cases there may appear an unusual mental 
acumen and facility of expression ; they converse with 
greater fluency, and use language with more ease in expres- 
sion than ever before ; are readily pleased, or quickly take 
offense when none was intended, and for such trivial causes 
40 



466 LECTURES ON MENTAL DISEASES. 

as would formerly have received no attention. At other 
times the mind gives evidence of increased ability to accom- 
plish work ; mental operations are quickened, and the imagi- 
nation is more than usually active and brilliant, but only for 
limited periods, which are quickly followed by weakness 
and lassitude. 

Other patients during this period become more or less 
careless as to dress and as to the claims and needs of their 
friends or families, thoughtless as to the future, more lavish 
in the expenditure of money for articles of little value and 
objects of small importance, and are over confident as to 
matters of uncertain issue. 

In case the change at first assumes the form of depres- 
sion, which is generally the case, it is of a mild character, 
and partakes more of hypochondria than of melancholia. 
Patients have periods of being unusually silent, often shed 
tears without apparent cause, and are not easily roused to 
take interest in their ordinary occupations, or in anything 
else. Sometimes there exists, at least in some degree, a 
realization that they are not well, and that they have lost 
their power of mental application, and their interest in and 
love of friends. They speak of this change freely, acknowl- 
edge that they feel badly, regret it, and thus excuse their 
neglect to attend to duties and their exhibition of irritable 
feelings and frequent explosions of bad temper. The 
memory gives indication of slight impairment ; the person 
is forgetful of appointments and careless as to personal 
appearance and dress. Such cases not unfrequently consult 
the physician and explain in some measure their changed 
condition, though more often this is not realized or appre- 
ciated. 

In addition to the above somewhat obscure mental symp- 
toms, which are rather suggestive than pathognomonic, 



GENERAL PARESIS. 467 

there may exist certain physical ones, which will tend to 
assist and confirm the diagnosis. One of these is a pain, 
not of a severe character, affecting- the frontal and some- 
times the parietal regions of the head. This is not usually 
so acute as to greatly annoy the patient, or at first to 
prevent his attending to business. Indeed, he rarely com- 
plains or speaks of it unless questioned, and then will admit 
that he has experienced it at times for months or for a long 
period. Two patients, which I have recently seen with 
other symptoms of general paresis, say that they have 
experienced such pains in the head at frequent periods, one 
of them during several months and the other for two or 
three years. 

The wife of a general paretic, who is in the Retreat at 
the time of this writing, in detailing a history of the case 
said that for several months prior to the marked indications 
of mental derangement he had been unable to attend to 
business, and had exhibited so much restlessness that the 
family physician was consulted, who said that he had 
" malaria," and prescribed large doses of quinine. She 
afterward went with him to the South, where they remained 
traveling about nearly three months. She often noticed at 
that time " a difficulty or hesitation" in pronouncing some 
words, but attributed no importance to it. This patient 
soon after his return home, one night suddenly became 
greatly excited and maniacal, which led to an examination 
by an expert, who at once explained the character of the 
disease to his family. 

All these indications of disease, however, often vanish in 
the presence of any excitement, and not infrequently in that 
attending the first visit to the physician. Besides, it will 
prove quite impossible to obtain such a medical history in 
the large majority of those cases which occur in the lower 



468 LECTURES ON MENTAL DISEASES. 

ranks of life. These initial changes, especially the physical 
ones, are so obscure that they have not been noticed, and 
in consequence of the character of occupations, could not 
be by non-professional observers. Only the more pro- 
nounced and easily recognizable ones which occur later on 
in the progress of the disorder can be recalled by friends 
and physician. It will be in those cases which occur 
among professional men, and those engaged in large busi- 
ness enterprises, that such a medical history as has been 
described may be observed, while in the larger majority of 
cases the friends will declare that nothing whatever un- 
usual has been noticed in the mental or physical condi- 
tion of the patient until within a very short period. When, 
however, inquiries are made, not infrequently it will be 
remembered that some of these obscure symptoms have 
appeared at times, for months or years, in the history of 
the individual. 

The recuperation of brain energy which ordinarily occurs 
during the periods of rest, diversion, and sleep is in partial 
abeyance ; the vaso-motor system is disturbed in its 
functions, causing a more or less irregular circulation in 
the brain cortex, and hence the mental functions common 
to it become irregular and in some degree abnormal. 



LECTURE XXVI. 



GENERAL PARESIS. (Continued.) 

Symptoms Become More Pronounced in Character — Increase of Irritability and 
Excitability — Egotism — Self-confidence — Extravagance of Projects — 
Sexual Excitement — Change in Moral Character — Failure in Memory — 
Mental Obtuseness — Insomnia — Depression not Unfrequently Present 
— Physical Symptoms — Vertigo — Incoordination of Gait — Tongue — 
Articulation — Spinal Symptoms — Disturbances of Circulation — Importance 
of Recognizing Early Symptoms — Symptoms of Pronounced Period 
— Excitement— Impairment of Judgment — Dementia — Memory — Atten- 
tion — Inability to Combine Concepts — Delusions of Great Wealth and 
Importance — Hallucinations — Emotional States. 

We now approach another stage in the development of 
what are usually described as the prodromatous symp- 
toms of general paresis. In this period a process of evo- 
lution in the changed conditions of mind and body which 
have been hitherto obscure appears to have taken place ; 
they all become more or less pronounced in character, and 
others arise in connection with them. 

While it is difficult to present a description or picture 
of the symptoms which will hold true as to the patient 
from day to day, for the reason that they are constantly 
changing in degree of intensity, and, in some measure, in 
character, yet certain characteristics may be indicated 
which will be found existing more or less in all cases if not 
at all times. 

The tendency to increase of irritability and excita- 

469 



47° LECTURES ON MENTAL DISEASES. 

bility, has been already alluded to as existing among the 
primary indications of change in mental character. This 
excitability becomes more marked as the disorder advances ; 
the patient walks with greater energy and for long distances 
without definite purpose or appreciation of what he is 
doing ; he becomes impatient of dictation or control, and 
assumes to give orders to others ; becomes excited if he 
cannot compass his desires ; punishes his children with 
brutality, and sometimes threatens violence to others. 

In connection with this state of irritability there often 
exists an unusual egotism and self-confidence which 
leads to new enterprises and large undertakings. In the 
case of a patient brought to the Retreat several years since, 
the friends stated that the first act which really aroused 
attention to the patient's altered condition of mind was the 
ordering a carload of potatoes, when he went to the market 
in the morning, instead of a bushel, as was his usual cus- 
tom. When remonstrated with he became violent and 
threatening in language, talked loud, and declared that he 
was not to be dictated to in providing for his family, which, 
by the way, consisted of himself and wife only. There 
can be no doubt that this very marked change had been 
preceded by many others of a less pronounced character 
during months and possibly for years. 

Another patient recently brought to the Retreat had 
been regarded as well until within a few days ; during this 
short period he had managed to squander the larger por- 
tion of a moderate fortune by unwise trades, and had 
undertaken to contract for the building of a hundred houses 
in the little village where he resided, with the view of a 
fabulous income from their rental. He was also negotiat- 
ing for a steamer with which he intended to make a voyage 
to India (he had formerly been engaged in trade in China, 



GENERAL PARESIS. 47 I 

and owned ships, or an interest in some) with one thousand 
of his friends as invited guests, all expenses to be paid by 
him. 

These extravagant projects, which are connected with 
delusions of self-importance and grandeur, often lead to 
loss of property, excessive brutality, and boastful conduct, 
while there still exists an appearance of sanity, and before 
the condition of the patient is appreciated by friends. 

This exacro-erated egotism, self-confidence, and excitabil- 
ity, which doubtless arises as a reaction from a former 
state of dullness attended with a diminution of functional 
activity of the cortex, or from impairment in the inhibitory 
centres, may manifest itself in other ways. The patient 
indulges in alcoholic excesses, invites friends or strangers 
irrespectively to indulge with him, and insists upon settling 
the expenses in the most lavish manner. In other cases the 
sexual centres become abnormally excited, and the patient 
begins to make love to the servant girls in his own house, 
and almost in the presence of his wife ; or, again, may leave 
his family and make proposals for new alliances or marriage 
with the street girls of the city, and in case he is unmarried, 
elope with one of them, while in conversation he becomes 
coarse in language and manners. A change in the moral 
character sometimes appears several years prior to the more 
marked and definite symptoms. Friends not infrequently 
infer that such a course of conduct in relation to alcohol 
and venery is the cause of the subsequent disorder, when 
in reality it is only an indication of a modification in the 
normal activities of the brain which has been going on for 
a considerable period. 

On the other hand, there may exist a partial or entire 
loss of sexual ability. This state had existed in a case 
which is under my care at the present writing during some 



472 LECTURES ON MENTAL DISEASES. 

months prior to his admission, and was among the earliest 
indications of disease as afterward recalled. 

The change in moral character may manifest itself in 
other ways, as in deception and motiveless lying, or in the 
purloining of articles of little value. A patient formerly 
under my care, at an early period in the disease, was 
detected in taking some small articles from the counter cf a 
store where he was calling and placing them in his pockets ; 
this tendency became more pronounced at a later stage in 
the progress of the disease, and no occasion to indulge it 
was omitted by him. The articles could be removed from 
his pockets or the drawers of his room where he had 
placed them, and he apparently never missed them. He 
always affirmed in the most positive and imperturbable 
manner that he had paid for them, or that the articles had* 
been presented to him by friends and had been in his pos- 
session for years. This patient, who was a physician, had 
married a mulatto woman two or three years before his friends 
instituted measures for his being placed under legal restraint. 

The failure in memory, already alluded to, becomes 
more pronounced. This more often relates to recent oc- 
curences or appointments, and is generally regarded by 
friends as mere forgetfulness or carelessness. The physi- 
cian forgets his appointment with patients ; the business 
man with his customers ; the clergyman the day of the week 
and the hour he has assigned for a particular service. The 
failure in memory may be observed especially in relation 
to dates and numbers. The adding of columns of figures 
or making mathematical calculations becomes very difficult, 
as does the committing to memory anything heard or read. 
In consequence of this impairment, most serious mistakes 
regarding agreements and property not infrequently happen, 
which serve to call attention to the approach of disease. 



GENERAL PARESIS. 473 

With the failure in memory comes also obtuseness and 
dullness in mental activity. The mind no longer initiates 
or enters upon new lines of thought, study, or business. 
The power of attention becomes impaired, and what is 
addressed to the person is only partially apprehended and 
soon fades from the mind, all of which is indicative of 
the approaching confusion of ideas and dementia, which 
will ultimately be one of the most marked indicia of the 
disease. 

Insomnia is very common as the early symptoms pro- 
gress in their development. This is not attended with any 
anxiety on the part of the patient in consequence of its 
experience, but, on the contrary, he pays little attention to 
it, rarely complains of any disagreeable feeling, and refers 
to it, if at all, as of no importance. In some cases in which 
the sleep is broken and scanty at night there may be 
drowsiness during the day. 

In contrast with the state of self-importance and excite- 
ment, there may exist in a certain proportion of cases, 
mental depression attended with loss of self-confidence. 
Patients become sad, unhopeful, inclined to shed tears, and 
experience a foreboding of something terrible about to 
happen to them. These conditions may increase until a 
true melancholia appears to be the leading feature in the 
mental state. This depression appears to be quite identical 
with that of ordinary melancholia, and the diagnosis of such 
cases will depend upon the history, as presented by friends, 
together with physical symptoms. It is not unfrequently 
attended with more or less uneasiness or positive pain about 
the epigastric region, indicating some lesion of the great 
sympathetic nerve. 

Dr. James S. Kiernan* presents a table of thirty-four cases 

* Alienist and Neurologist, January, 1885, pages 65 and 66. 



474 LECTURES ON MENTAL DISEASES. 

in which depression existed as an "early mental symptom" 
in thirty-two. This is certainly a higher proportion than 
has existed in my own experience, though according to the 
statement of friends it has existed in from 50 to 60 per cent. 
As the disorder progresses so as to attract the daily attention 
of friends, the leading characteristic becomes one of irrita- 
bility and excitement in the great majority of cases. 

Physical Symptoms of this Stage. — The late Dr. W. 
B. Goldsmith* says that epileptoid seizures in some form 
had existed in twenty of the one hundred cases which had 
been under his observation as one of the earlier indications 
of approaching general paresis. This is a much higher per 
cent, than has existed in my experience, such seizures 
being confined almost entirely to the third period of the 
disease. 

Vertigo. — There is a case under my care at the time of 
this writing, in which the first indication recognized by the 
patient himself or his friends consisted in an attack which 
was described as " vertigo and slight faintness," requiring 
the patient, who, at the time was engaged in his store, to sit 
down for a few minutes. He, however, did not lose conscious- 
ness, soon arose, and going immediately to his physician 
explained the character of the attack. He experienced no 
other of any kind, and appeared to his friends to be in his 
usual state of health during several months. Being some- 
what over-heated and fatigued at his place of business, in 
the month of June, he laid down for a sleep in mid- day. 
After a short time he awoke in a delirious condition, in 
which he continued, a part of the time greatly excited, 
during three or four weeks. The delirium and excitement 
then gradually passed away, leaving the mind at times 

* Archives of Medicine, August, 1883, page 50-57. 



GENERAL PARESIS. 475 

confused and with delusions of importance. He has had 
no attacks approaching the nature of an epileptic form of 
seizure, or loss of consciousness, or even vertigo, to the 
present time, a period of nine months, though other symp- 
toms are well marked. 

Dr. Mickle* says that " vertigo, whether slight or severe, 
and occurring independently of gastric disorder, is not at 
all rare at this preliminary stage. " 

An impairment in coordination of gait appears so 
plainly as to be readily observed in a small proportion of 
cases before the mental symptoms are pronounced. In 
a case under my care several years since, the wife told me 
that this had existed to such a degree that when walking 
upon the sidewalk with her he would at times require her 
support to prevent his staggering against those whom he 
met. When alone he generally went near the fence, so as to 
support himself if necessary, as it often was. This char- 
acter of gait had existed several months before any change 
in his mental condition was observed and he was brought 
to the Retreat. Tabes dorsalis was not a prior condition 
in this case, and the disease was in no other wise excep- 
tional in its course or symptoms. 

In a much larger per cent, of cases there is observed a 
failure in the finer movements of the tongue, in articulation, 
and also in the manner of its protrusion. This is done by 
a sudden movement, and then it is almost as quickly with- 
drawn. An unusual effort to keep the tongue extended 
appears to be necessary, and the patient requires several 
invitations before he will keep it out long enough to be 
carefully examined. When it is fully protruded, there will 
often be seen a twitching of the muscular fibrillae of 
the surface. Such a movement on the surface may, how- 

* Mickle on " General Paralysis of the Insane," p. 9. 



476 LECTURES ON MENTAL DISEASES. 

ever, exist in other conditions than that of general paresis. 
The difficulty in articulation will be observed more partic- 
ularly in the effort to enunciate words beginning or ending 
with consonants and those containing a number of con- 
sonants. 

When spinal symptoms appear first in the course of 
the disease, patients often complain of neuralgic pains in 
the head and neck, and about the loins, and in the legs, 
attended with cramps of the muscles of the soles of the 
feet and calves of the legs. In the case of a female patient 
at the Retreat, such pains, according to the statement of 
her husband, had existed at times for six years before the 
mental symptoms appeared. Whenever these pains sub- 
sided, as they frequently did, there occurred numbness, and 
at times loss of sensation in feet and ankles. The ataxic 
gait had been present during several years. It does not 
appear that the anaesthesia in this case preceded the 
motor disturbance as a primary symptom. It certainly 
remained a prominent one for months after the mental 
symptoms were pronounced, and a pin could be inserted 
without causing the slightest pain 

In other cases there may occur disturbance of the cir- 
culation, palpitations, heat in the head, a congested state 
of the capillaries of the face, or ringing in the ears. 
I infer from my own experience that these symptoms are 
less common than many others in the earlier stage, though 
they often appear later. 

The character of the initiatory symptoms will depend, 
at least to some extent, upon the etiology of each case. 
This will be true especially in those cases resulting from 
injuries to the brain and nervous system, sunstroke, and 
poisoning by lead, and also when the disease is preceded 
by tabes dorsalis. 



GENERAL PARESIS. 477 

It will be observed that so far in our enumeration of 
primary mental symptoms none have been described 
which appear in the classical literature of general paresis as 
pathognomonic. Moreover, nearly all cases in which the 
law interferes and restricts the liberty of the individual 
have progressed to another stage and exhibited symptoms 
of a much more pronounced character. The general 
practitioner, therefore, who searches for those conditions 
only which constitute its typical character, as described by 
Skae, Calmeil, and the earlier French authors, will utterly 
fail in forming a correct diagnosis. Yet the importance of 
a recognition of these early indications, both from a 
medico-legal as well as a social point of view, can hardly 
be over-estimated. Fortunes have been squandered, public 
trusts betrayed, positions of influence, which have been 
secured as the reward of years of faithful service, have 
been lost, morals have been outraged, and family ties sun- 
dered, all before the true cause has been understood. 

Pronounced Period. — The initial period varies greatly 
in duration in different cases, in some covering several years, 
and in others a few months, or even weeks. This will 
depend largely upon the exciting causes and the inheritance 
of the individual. Whatever has been the length of time, 
however, since a change may have been observed, it seldom 
happens that the patients are placed under asylum super- 
vision until the occurrence of some act, or a series of acts, 
which are manifestly so abnormal and foreign to the pre- 
vious character as to make this step necessary. 

In some cases this will consist in an outburst of excite- 
ment or the undertaking of some great financial scheme ; 
in others an inability to be longer interested or occupied in 
former pursuits and a consequent vagrancy ; in others still, 
the commission of some moral delinquency, such as a theft, 



47§ LECTURES ON MENTAL DISEASES. 

embezzlement of funds, or an indecent exposure of person 
iu public, or an attempted outrage upon some female. Dr. 
Kiernan has cited the case of a professional man who was 
arrested for indecent exposure, fined by the court, and after 
release retired from the immediate presence of the court- 
room and repeated the offense. But in whatever form of 
conduct this may appear, it is of such a nature as to indi- 
cate a profound change in the mental state of the individual, 
and, more often than otherwise, incapacity and impair- 
ment of judgment. Indeed, so generally is this the lead- 
ing character of mental change that some authors have 
christened the disease paralytic dementia. 

The dementia of the second period of general paresis is 
of a special order. It does not consist so much in an 
absence of mental activities, as in an impairment of their 
integrity. There is not an absence of, but a diminution of, 
mental activities, and a weakening in their character. The 
inhibitory centres are in a condition of partial paralysis, and 
both language and movement are characterized by little 
restraint, and eventuate in what appears to come from the 
instinctive or acquired habit of the brain. Ideas are dis- 
jointed, confused, fragmentary, with little or no coordina- 
tion or logical sequence. 

The lesion of memory appears to be one of the most 
important elements in this impairment of mind. This is 
largely of the same nature as pertains to old age. It does 
not relate so much to those experiences which occurred 
fifteen or thirty years before, or during childhood, as it 
does to the occurrences of yesterday or those of an hour 
ago. Some patients will relate correctly the happenings of 
long ago, unless it may be their date, and yet be utterly 
unable to tell whether they have had their dinner or what 
is the day of the week. One may recognize the face of the 



GENERAL PARESIS. 479 

friend of years ago, and yet cannot possibly say he has 
ever before seen the face of the physician who visited him 
in the morning. He has no recollection of having incurred 
a debt, or of having paid the bill, or of its amount, and 
therefore " could be cheated ten times a day, if nine were 
not sufficient for your purpose." 

As capacity of attention is essential to integrity of 
memory, we could predict a lesion of this as having existed 
prior to that of memory. In this second period it becomes 
more and more difficult to secure continued attention, and 
consequently the accomplishment of any trifling task or 
even the writing of a letter becomes greatly more difficult. 
The patient may be engaged in recounting some vague 
delusion of personal importance or of vast wealth, and yet 
be diverted by the slightest occurrence. The mind, how- 
ever, if left to itself, again soon reverts to the delusions 
which appear to be floating in the field of a semi-conscious 
condition of the brain. At another time the patient may 
be occupied in removing his clothing or that of some other 
patient under the impression that it is his own. 

The dementia manifests itself not only in lesion of 
memory and the capacity of fixed attention, but also in 
inability to normally coordinate mental concepts. Instead 
of a combination and unification of these concepts into ideas 
and judgments which would be normal to the brain, they 
become fragmentary, improbable, and absurd ones. When 
the suggestion of money or its equivalent reaches the brain, 
it becomes expanded at once into the delusion that the sub- 
ject is the happy possessor of great riches. The possession 
of a few pebbles, bits of glass, or old buttons in his pocket 
makes him the owner of untold wealth. The sight of a 
child leads to the belief that he has a family of the most 
lovely ones that have ever been born. The mention of a 



4§0 LECTURES ON MENTAL DISEASES. 

political office awakens in his mind the belief that he has 
had, and still has, some of the highest which are within 
the power of his fellow-citizens to bestow. He at once 
becomes the Governor of the State, or the President of the 
United States, or an Ambassador to some foreign court, 
where he will be happy to present you to the Emperor 
or Queen. 

At other times the bits of glass become diamonds, and 
his benevolence boundless. He intends to make the largest 
benefactions to all friends and relatives, erect hospitals for 
the sick, and libraries for the free use of everybody. There 
will no longer be need of suffering or ignorance, which will 
have an existence only in the memory of by-gone days. 
These pleasing delusions seem to be glorious realities, and 
are recounted again and again with a countenance beaming 
with self-satisfaction and joyousness, and yet with a stam- 
mering tongue and half-paralyzed lips, to any passer-by 
who will listen to the story. They will depend as to their 
material largely upon the antecedent experiences and 
education of the brain ; those of the ignorant or un- 
educated person will cover a field which will be totally 
foreign to the disciplined mind of a professional man, but 
the essential character of expansiveness and largeness 
belongs alike to both. 

A pleasing sensation becomes magnified a thousand fold. 
The patient is the happiest person in the world, — has never 
been in such perfect health ; he weighs one thousand pounds ; 
is eight feet in height; has walked one hundred miles 
with his attendant this very morning, and carried the world 
with ease on his shoulders ; and yet to-morrow may be- 
come emotional, irritable, fault-finding, and changeable. 
With tears and painful anxiety, he will tell you that his 
wife has left his home, and it is of the first importance 



GENERAL PARESIS. 48 I 

that he leave by the next train ; or again, that his children 
are dead, his house burned to the ground, and his wife 
locked up in the State prison, or that she is a fugitive with 
some scoundrel who has seduced and inveigled her from her 
home. He is positive that this is all true, for he saw it with 
his own eyes last night. At the next visit you shall find 
the patient with some book or a newspaper in his unsteady 
hand which he has been fumbling over, but not reading. 
He greets you with an affectionate welcome ; a pleasant 
look is on his countenance, and he makes no allusion to 
the strange story he told you in the morning. That sad 
vision seems utterly to have faded from the brain, and now 
he is serene and laughs at nothing, with a silly, imbecile 
laugh which causes the half-characterless face to become, 
if possible, more characterless still. All is now well with 
him again ; he has not a care in the wide world, and you 
are his best friend. 

On another occasion the patient will confidentially tell you 
that he has adopted a son and heir to his fortune, and leads 
you to a primary dement, who he declares is a very Apollo 
in beauty; he smooths his hair, brushes his coat, and 
assists in putting it on, and then goes with him for a walk 
on the lawn or to the chapel. He sits beside him and lifts 
his drooping head and gazes upon his idiotic face with as 
much of rapture as he is capable of feeling. After the chapel 
exercise is over, he buttons his coat for him and leads him 
carefully back to the hall, and yet in a short time he has 
ceased to remember that he ever expressed the slightest 
interest in him. 

In some cases the sensory system becomes largely af- 
fected, and the mind of the patient is absorbed by hallu- 
cinations of some of the special senses. He walks back 
41 



4^2 LECTURES ON MENTAL DISEASES. 

and forth in the hall with eyes intent upon an imaginary 
vision of some face or person, with whom he holds con- 
verse ; again he rushes to the window and talks with some 
one outside ; and at another time he holds long conversa- 
tions with the clock on the mantel, whose ticking he believes 
to be the sound of a voice whose subject is concealed 
within it. He is delighted with the charming sounds which 
respond to him, and fully believes that all is a reality, and yet 
forgets it on the slightest intimation from an attendant that 
he is ready for a walk around the court or a ride to the city. 

The character of hallucinations, like the other symptoms 
in the emotional general paretic, frequently changes. The 
patient who to-day has seen his wife and children, and 
carried forward a delightful conversation with them, may 
to-morrow tell you that he saw them scattered from their 
homes and among strangers. To-day he sees the bare 
walls of his room hung with priceless pictures from the 
studios of the greatest living artists, and to-morrow he will 
tell you that he sees nothing but horrible daubs on them. 
To-day he hears music which is being made for his special 
delectation in the next room, and to-morrow he will tell 
you that during the night he heard the sobs and groans of 
his poor children coming from the same room. 

Hallucinations of sight and hearing, according to my 
experience, are the most frequent in the pronounced period 
of general paresis. Hallucinations of smell have been 
rare ; while those of general sensation have been confined 
almost exclusively to the later periods, except those relat- 
ing to the sexual organs. In a report of the private 
asylum at Ober Darbling, Austria, mention is made of an 
investigation on the subject of hallucinations among gen- 
eral paretics, with the result that they were found in only 



GENERAL PARESIS. 483 

twenty out of 194 cases.* This is a considerably lower 
percentage than I have found in cases at the Retreat. 

And here it may be noted as characteristic of the 
emotional general paretic, that his conduct is at entire 
variance with the delusions which have occupied so large a 
place in his mental operations. All the grand offices he 
has occupied or is about to possess; the billions of golden 
sovereigns he has on his person ; the lovely children he is 
the fortunate father of; the visions of charming faces with 
which he has held converse ; the horrible scenes of his 
night-waking hours, in which he has seen his home burg- 
larized, his wife taken away and ravished in his very 
presence, and his children orphaned or dead, — all these 
pleasing or horrible visions, with kaleidoscopic movement, 
vanish, and he will be as happy or miserable as if he hag! 
never experienced such delusions and seen such visions. 

* Journal of Insanity, p. 392. 



LECTURE XXVII, 



GENERAL PARESIS. (Continued.) 

Depression — Much Less Common During the Pronounced Period than Exalta- 
tion and Elation — Melancholic Symptoms May be Present — Periods of 
Excitement — Illustration — In Some Cases Neither Excitement nor Depres- 
sion Exist — States of Elation May become Changed by Suggestions — Ex- 
travagance of Delusions — Physical Symptoms of the Pronounced Period — 
Tongue — Lips — Muscles of the Face — Handwriting — Epileptiform Seiz- 
ures — Corpulence — Gait — Eye Symptoms — Period of Boasting — Increase 
of Dementia — Paralysis — Sphincters — Convulsive Seizures — Bed-sores — 
Bone Fractures — Case. 

Depression. — In my own experience the symptoms of 
depression and melancholia have been comparatively rare 
in the pronounced period of general paresis, and yet, at the 
time of this writing, there are two such cases in the Re- 
treat. According to the statements of friends, one of them 
had never presented symptoms of excitement or exhilara- 
tion prior to his admission, and since then the mental state 
has been one of depression. The hallucinations and delu- 
sions partake of this character, and render him exceedingly 
suspicious. He says that he sees persons entering his 
room at night, sometimes by the windows, and at others 
by the doors, and he is confident that they are his enemies, 
that at times they take a camera into the room for the 
purpose of securing a photograph of him. At other times 
they pound his feet and legs until they become black and 
blue, and in evidence of this he begs you to examine them 

484 



GENERAL PARESIS. . 485 

for yourself. At other times he hears them shouting at 
him and defying him to come out and defend himself if he 
is able. During the day he believes that these persons 
are the attendants of the hall, who have been in the habit 
of disguising themselves at night for the purpose of annoy- 
ing and injuring him. On many occasions, under the influ- 
ence of this suspicion, he, has endeavored to be avenged 
by stealthily approaching them with a chair in hand, while 
they were engaged, with the purpose of striking them. 
When remonstrated with, he freely says that he would like 
to kill them, that they have haunted his rooms, persecuted 
and insulted him long enough, and he is unwilling to 
endure it longer. This patient experienced an epileptoid 
seizure soon after his admission, and remained in a partial 
hemiplegic condition for nearly three weeks. 

General paretics sometimes present symptoms which are 
characteristic of melancholia. They refuse to take food 
lest it shall never pass from their bowels, or they refuse to 
go to the water closet lest they may contaminate it, or 
somebody who may be near it; they urinate in their 
rooms at night or out of the open window ; they are silent, 
dejected, and mutter to themselves in some manner expres- 
sive of regret or remorse, and apparently suffer more or 
less physical discomfort in the epigastric region. Such 
conditions, however, are generally confined to the initial 
period, rather than to the pronounced stage, and when 
present alternate with a state of mild exaltation. 

The passage from the initial to the pronounced period 
occurs in many cases by an explosion of excitement. 
The patient leaves his home, makes contracts for immense 
business undertakings, insults females in open day on the 
street, orders a cloak for his wife which is to be covered 
with diamonds, or purchases the entire contents of a 



486 LECTURES ON MENTAL DISEASES. 

jewelry store, and when arrested or interfered with, he 
bursts forth in a torrent of denunciation and abuse of every 
one who seeks to restrain him. Neither wife, children, nor 
friends produce the slightest effect in their efforts to reason 
with him. The subject of his talk is nearly always bur- 
dened with expansive delusions, which relate to himself and 
what he is about to do for others, and yet, as in conditions 
of mind already referred to, the element of change is always 
observed. There exists no logical sequence of ideas ; 
any one has no immediate connection with that which has 
immediately preceded it, nor does it suggest what will 
follow, and, indeed, may be entirely, contradictory. It is 
true that all considered together may appear to be the out- 
come of a semi-realized delusion of great wealth and of 
vast importance, but the individual concepts used to ex- 
press this delusion have very little, if any, relation to each 
other. 

These attacks of maniacal excitement are seldom of long 
continuance, rarely extending longer than a few days or 
weeks, and sometimes only during a few hours. But while 
they continue they constitute some of the most anxious 
periods which ever occur in any form of insanity. Patients 
sometimes do an incredible amount of injury in a very 
short time, which may relate to property or persons. 
Houses are burned, windows and doors are smashed, furni- 
ture destroyed, and wife or children may be killed. If in 
an institution they will attack attendants if sharply or sud- 
denly contradicted or interfered with. They are without 
appreciation of their surroundings, and hence are without 
fear, and will struggle and fight with ten men as readily as 
with one when once aroused to a conflict. And yet in 
the midst of the highest excitement the skillful attendant 
will often succeed in changing the current of delirium and 



GENERAL PARESIS. 487 

modifying the excitement by suggesting some other sub- 
ject of thought. 

As illustrating this point I may mention an occurrence 
which took place in one of the halls of the Retreat. On 
the occasion of a visit to the hall, in which there was a 
general paretic in the early stage of the pronounced period, 
I found him striding from one end of the hall to the other 
in the wildest condition, and shouting forth a storm of 
oaths, denunciations, and incoherent language. All indica- 
tions of physical impairment had left him, and words of 
one kind and another poured forth in a continuous stream. 
After a short time he saw me observing him, and at the 
same time seized a settee so heavy that he could with 
difficulty have lifted it while in his ordinary condition, 
raised it in the air, apparently with perfect ease, and with 
the intention of dashing it through the guard of the win- 
dow. His attendant, who had been near him, observing 
every movement and waiting for the storm to pass by, 
immediately stepped to his side, put his hand on his arm, 
and in a quiet voice, and in a perfectly self-possessed man- 
ner, said something to him which seemed to act with the 
magic of a charm by distracting his attention. Within 
thirty seconds he was assisting his patient in placing the 
settee on the floor, upon which they immediately sat down, 
while the attendant became a profoundly interested listener 
to the recital of some train of delusional talk. 

Such attacks have rarely occurred in my experience 
except during the pronounced period of the disease, though 
they may be present at a later period. They, however, 
become modified and limited in intensity as the disease 
progresses. 

There are other cases which are neither excited, de- 
pressed, nor emotional. They are perfectly calm, make no 



488 LECTURES ON MENTAL DISEASES. 

requests or complaints, express neither satisfaction nor dis- 
comfort, but seem to accept the present conditions with little 
or no realization of their meaning, and with no care for a 
different order. A patient who recently died at the Retreat 
exhibited this character of symptoms from the time of his 
admission. He had conducted a large business, and neces- 
sarily associated with many persons living in different sec- 
tions of the country. He had been fairly successful in his 
way, and accumulated a considerable property. Yet after 
his admission he never referred to his past experiences or 
inquired for his former friends. When his relatives called 
to see him, as they occasionally did, he replied to their 
inquiries at times correctly and at others incorrectly. He 
never expressed pleasure or displeasure on the occasions ot 
their visits nor requested them to come again. He would 
never write or take interest in letters written to him. He 
was always unwilling to leave the hall where his room was 
for exercise or for any other purpose, but was accustomed 
to spend the time in looking from the windows upon the 
lawn, or in walking from one end of the hall to the other 
in a slow and measured manner. Some two or three 
months after his admission he appeared to lose his personal 
identity, and when adressed by his name would correct the 
person and Say that his name was Johnson. This seemed 
to impress his mind so ^strongly that ever afterward he 
would become angry if he was addressed by his own or 
any other name than that of Johnson. After a residence 
of sixteen months, during which time he never, so far as is 
known, expressed a regret or pleasure, he experienced a. 
epileptiform seizure of a serious nature, from the immediate 
effects of which he did not recover. 

The above case was unusual in the almost total absence 
of emotional expression or desire, but cases simulating it in 



GENERAL PARESIS. 489 

character, though less pronounced, are not rare. The loss 
of personal identity has always, in my experience, except 
in this case, been associated with delusions of grandeur, and 
is often changing from that of one person or being to an- 
other. If a patient loses his identity he becomes some 
person or being of vast power and influence. Indeed, it is 
not uncommon for patients to conceive that they have 
Omnipotent power and are possessed of the attributes of the 
Deity. In but one case of depression or of indifference has 
this form of loss of identity occurred in my experience. 

It is characteristic of many patients that when the pre- 
vailing emotion is one of elation they can be made to weep 
by merely suggesting a mournful thought or some sad 
occurrence. The rehearsal by patients of the vivid experi- 
ence of a disagreeable dream of the past night, in which 
their children or friends appeared to be in danger or dis- 
grace, may wholly change the mental state from one of 
great elation to one of deep depression and sadness for the 
time being. 

It may be added that in no other form of mental disease 
does the character of delusions, whether they are those of 
elation or depression, assume such preposterous extrava- 
ance, and with absolutely no basis of reality, as in general 
paresis. 

Another case resembling the above in some respects 
was admitted to the Retreat in 1879. He had been em- 
ployed as a traveling salesman, and had been regarded as 
in good health until his return home on one occasion, when 
he appeared a little dazed and unable to give an account of 
himself, except that he had been robbed in a sleeping-car 
in New York. It was soon ascertained that the memory 
was seriously impaired, so much so that he was unable to 
tell an occurrence ten minutes after it was past. 
42 



490 LECTURES ON MENTAL DISEASES. 

At the time of admission he had a good-natured, facile, 
satisfied, don't-care air about him; had no objection to 
remaining as long as we should choose, though he left a 
sick wife and a little five-year-old daughter dependent on 
friends for support. He had no impairment of gait, never 
had been excited at any time, but, on the contrary, was 
eminently quiet, good-natured, and satisfied ; used to see 
his wife and children often, but never alluded to returning 
home with them, nor seemed anxious about either them or 
himself. He had some of the well recognized indications 
of general paresis, i. e. } epileptiform convulsions, defective 
articulation, peculiar and flaccid expression of face, impaired 
memory and weakening of the mind, entire satisfaction with 
everybody and everything. The twitching of muscular 
fibrillar was present on the face and tongue, but the hands 
and legs were firm and steady, and he walked without 
difficulty. He had a convulsion as often as once a month 
after admission and finally died from the effects of one, 
having never been either excited, depressed, or emotional. 

Physical Symptoms of the Pronounced Period. — All 
the physical symptoms which have been described as at 
times present in the initial period become exaggerated 
during the pronounced period. This is especially indi- 
cated in the motor disturbances of the tongue and lips in 
articulation, and in all the finer movements of the hands 
and fingers. When a little excited by meeting you, and 
during the first few minutes, the excitement may be suffici- 
ent to enable the patient to articulate so perfectly that no 
defect will be noticed, but as the attention is diverted the 
failure becomes apparent in some portions of almost every 
sentence, and is more noticeably so in sentences composed 
of sounds with sequential labials and consonants. When 
requested to repeat as a kind of test sentence — " Round 



GENERAL PARESIS. 49 1 

about the rugged rocks the ragged rascal ran," the patient 
starts off with large confidence, but will rarely get beyond 
the third or at most the fourth word which begins with an 
" R; " the tongue and lips utterly fail in the effort at co- 
ordination in pronouncing the words beginning with the 
same letter, and he brings up in confusion and yet smiling 
at his failure, having said, " Round about rug-rock " or 
" Round the rock the rug-rus," or again, " the Rugged rascal 
rascal ran." If asked to extend the tongue, he is unable 
to more than half protrude it from the mouth, or to hold 
it out long enough for an examination. It is often in a 
soft, flabby condition, easily indented by the teeth, and 
covered more or less with a creamy coat. 

But the paretic condition is manifest not only in the 
motor disturbances of the tongue and lips, but also in the 
soft, puffy, smooth appearance of the whole face ; it is the 
face which is so characteristic of chronic alcoholism. 

The tense condition of the facial muscles, which is so 
essential in giving expression to the individual character of 
the person by means of the lines or wrinkles it causes to 
exist, becomes relaxed, and the countenance is changed 
and comparatively characterless. 

The paretic condition is observed to have extended to 
the muscles of the hands and fingers, and becomes apparent 
in the execution of all the finer movements essential in 
playing a musical instrument or in writing. The patient 
will begin to write a letter in good earnest, and succeed in 
forming the letters of the first few words with some regu- 
larity by an unusual effort, but the hand soon gives evidence 
of weakness, the pen is not held steadily on the paper, 
the lines become irregular and tend downward or upward 
on the page, words are omitted, the ideas become confused 
and appear to fade from the mind before he succeeds in 



49 2 LECTURES ON MENTAL DISEASES. 

getting them on paper, and the effort is soon abandoned. 
The patient will not try to write again until the result of 
this time has passed from the mind. 

Some paretics, however, have a special inclination for 
writing so-called legal or diplomatic documents. The 
address and the first few words may be legible, but the 
writing soon degenerates into a mere, irregular, puzzling 
scrawl, and the page is half covered with blots and erasures. 
Very likely the signature at the close of the page will be 
the most irregular and illegible of all. When finished the 
bit of dirty paper which has been torn from a book or from 
an old letter is crudely folded or crumpled together, after 
an attempt has been made to address it to some high 
functionary or to the President of the United States of 
America. 

Reference has been made to the infrequency of epilepti- 
form seizures during the initial period. They are more 
common during the pronounced period, though less so than 
during the third period and toward the end of life. Head- 
aches are rarely complained of during this period, but 
a confused state of feeling in the head and vertigo 
are sometimes referred to. A congested state of the 
capillaries of the face, which at times extends to the 
scalp and which is due to vaso-motor disturbances, is 
often observed. 

During the earlier part of the pronounced period patients 
are often restless and inclined to walk. If in the hall they 
continue by the hour to walk from one end of it to the 
other. It would seem that they had a premonition that 
the time was speedily approaching when they would no 
more be able to walk except with halting and difficulty ; 
they therefore walk with their might while the day of their 
walking ability lasts. 



I \ 




\4 




493 



jtd oJVv **&&> 

Specimen of Handwriting in Last Part of Pronounced Period. 

494 



49^ LECTURES ON MENTAL DISEASES. 

In other cases the failure of coordination in walking 
becomes pronounced ; the patient is uncertain of his balance 
and unconsciously spreads his feet to provide a broader 
basis on which to stand ; when standing before you he 
moves, lest he fall, and if asked to close his eyes or look 
up to the ceiling at once begins to fall. Such patients 
rarely make the requisite effort to walk much, and are 
generally found on a chair or the lounge. A kind of 
clumsiness and want of elasticity in the walk are nearly 
always present in this stage. 

One of the most constant symptoms during the latter 
portion of the pronounced period is a tendency to cor- 
pulence. The appetite is very keen and the patient takes 
an unusual amount of food at every meal. He is not so 
much interested in the quality as in the quantity placed 
before him, and as the period of restlessness and increased 
motor activity passes by the increase of adipose tissue 
becomes especially noticeable. 

The group of eye-symptoms, some one of which is 
usually present during the progress of general paresis, is 
extremely interesting and of sufficient diagnostic impor- 
tance to require special attention. 

Both inequality and irregularity in the shape of the 
pupils are of frequent occurrence, though in a considerable 
per cent, of my own cases neither of these conditions has 
been apparent during the first stage. 

A persistent dilatation (mydriasis) is not unfrequently 
present during both the early and later stages of the dis- 
ease. I have at the present writing a patient whose pupils 
are unequal during some portion of every day, and the 
pupil which is the most dilated during the morning fre- 
quently becomes the smallest in the afternoon. Both pupils 
react sluggishly when exposed to the stimulation of sun- 



GENERAL PARESIS. 497 

light. The edges of the left pupil become irregular, so that 
the two sides do not appear exactly alike nor conform to 
the normal outline. In two of my other cases now under 
treatment the so-called pin-hole pupil was present during 
a portion of the pronounced period. 

The state of the pupil does not appear to be affected by 
the mental condition, whether it be one of excitement or 
depression. One of the patients above referred to as hav- 
ing the pin-hole pupil at the same time experienced periods 
of great excitement. When irregularity is present it may 
appear in one or both pupils and frequently change. 

In short, it may be stated that the pupils in general par- 
esis sometimes present inequalities in size, irregularities, 
abnormal dilatation and contraction, abnormal insensi- 
bility to the stimulus of light, with failure in accommo- 
dation. Also that these different abnormal conditions of 
the inner muscles of the eye may be present singly or 
together, and also during any of the stages of the disease; 
that some of them are more frequent during the early 
stages, while others are more often observed in the later 
stages. It may be added that insensibility to light stimu- 
lation and loss of movement in accommodation are more 
frequent in those patients whose pupils are habitually con- 
tracted, though it may be present in both contraction and 
dilatation ; and also that the small pupil which is frequently 
found in the early stage may continue to exist through the 
pronounced and final periods. 

Of other eye- symptoms which are occasionally present 
may be mentioned : — 

1st. Paralysis of the ocular muscles, resulting in strabis- 
mus. This occurs more often during the later portion of 
the pronounced period and during the period of wasting, 
and is attended with disorders of vision. 



LECTURES ON MENTAL DISEASES. 

2d. A progressive failure of sight may occur. This 
may be partial and relate only to colors or distances, or it 
may be general and due to progress of disease in the 
optic nerve, and in some cases to increasing dementia. It 
may affect one or both eyes. It has been observed as 
existing during several months, and according to Foville 
several years, before any more definite characteristic symp- 
toms appeared. 

3d. Atrophy of the optic nerve has also been noted 
as among the earliest indications of approaching general 
paresis. 

The Period of Wasting. — The duration of the pro- 
nounced period of general paresis varies very considerably 
in different cases, and extends from a few weeks or months 
to a year or longer. The transition from this period 
to that which has been termed the period of wasting 
is rarely sudden, unless it may be ushered in by an epi- 
leptiform seizure. On the contrary, it appears to take 
place gradually and by a process of involution, so far as 
pertains to the mental symptoms. It will be remembered 
that the passage from the primary symptoms of the initial 
period to those of the pronounced period was characterized 
as one of evolution ; that is, the symptoms gradually 
became developed from a morbid state of mental action, 
which was really a prophecy of what they actually afterward 
became during the pronounced period of the disease. 
Now, in reaching the final period, an opposite process 
occurs, and there results an involution of these morbid 
mental activities. The mind becomes more sluggish in its 
action, the patient is less talkative, and the delusions when 
referred to appear less distinct in the disordered field of 
consciousness. It becomes necessary to question the 
patient in regard to them in order to ascertain that they 



GENERAL PARESIS. 499 

still in any measure remain. In some cases patients deny 
that they have them, or that they have ever entertained 
them, and will look at you with incredulity when told that 
they formerly held and talked about such delusions. In 
other cases they will still affirm their belief in them, but 
only as they are suggested ; they appear to be half for- 
gotten, and remain in the mind in a sort of latent state, 
the brain centres requiring some stimulation to call them 
forth. The hallucinations become less vivid and are rarely 
referred to, and suspicions have little of reality. 

In case there has existed depression or excitement, 
mania or melancholia, or exhibition of abnormal egotism, 
all these conditions may largely fade away and the patient 
appear to be insensible to those stimuli which have acted 
heretofore to develop these abnormal forms of mental 
activities. He may appear improved in mind, and yet 
rarely, or never, allude to returning home in consequence 
of his improvement. He may not often realize that he has 
a home, or if he has, that he is not already in it. At times 
he believes that his room is his home, and as he looks from 
the windows that the grounds are his own. An Italian 
count was under my care a few years since, who, during 
the earlier portion of this period, was always insisting when 
I saw him that the Retreat was his old castle situated 
among the mountains of Italy, and that the grounds were 
a part of his hunting park; with his hand on my shoulder, 
and with stammering tongue and lips, he would insist that 
his hounds were in waiting, and that he would go with me 
at any time for a hunt through the forests. At the same 
time he could not take two steps without staggering about 
and seeming to be in danger of falling. 

Finally, the recollection of even the oldest memories is 
at fault, and the mind becomes more and more unable to 



500 LECTURES ON MENTAL DISEASES. 

fully realize and appropriate any of the impressions which 
reach it through the avenues of sensation. The patient 
takes little or no account of time or of present environ- 
ments. Morning is as the evening, and one day as another. 
He asks for nothing because he does not suffer for the 
want of anything, and is entirely oblivious to the utter 
wretchedness of his condition. His mind has gradually 
gone down step by step toward a state of the darkest 
fatuity. He is literally beyond the need of human 
sympathy or aid, and thus stumbles on toward the grave 
which is awaiting his advent. 

Physical Symptoms of the Period of Decay.— The 
patient, however, reaches this goal not through the agency 
of morbid mental activities. It has already appeared that 
there has been a gradual disappearance of these, excepting 
that of dementia. Such has not been true as to the phy- 
sical lesions. These have become more and more serious 
through a continuous evolution. The incoordination of 
the muscles of the fingers, hands, arms, and legs has con- 
tinued to become more pronounced, until it has reached a 
condition in which it is impossible to write a legible line or 
to walk from one end of the hall to the other. The ability 
to articulate words and form them into sentences has dis- 
appeared, and when about to make an effort to reply to any 
question, the corners of the mouth will twitch, the orbicular 
muscles contract in a spasmodic manner, the tongue moves, 
and the air passes over it, but there results an almost entire 
failure in all the more delicate movements of tongue and 
lips, which are essential to the articulation and full pro- 
nunciation of the desired words, and in consequence they 
coalesce, become mixed and jumbled together, and mean- 
ingless. This, however, does not annoy the patient, as he 



GENERAL PARESIS. 501 

fails to realize that he has not already succeeded in render- 
ing the desired reply in a satisfactory manner. 

The paretic condition gradually extends to other muscles, 
especially those concerned in the act of deglutition. The 
patient, therefore, will be in frequent danger of strangula- 
tion in his effort to swallow what is placed in his mouth, to 
satiate his morbid craving for food. 

The sphincters also, sooner or later, sympathize in the 
general paretic and anaesthetic condition ; the bowels fre- 
quently move several times daily, and the patient requires 
the utmost attention to render his presence in the hall en- 
durable, and also to prevent the formation of bed-sores. In 
some cases there may occur retention of urine without the 
knowledge of the patient. The general anaesthetic state is 
so pronounced that the urine may accumulate to the 
amount of several pints without apparent inconvenience. 
The gradual dribbling of it on the clothes and while in bed 
does not entirely relieve the bladder. It becomes necessary 
in such cases to use the catheter twice at least every twenty- 
four hours, This, with a frequent change in the bed- 
clothes, will be one of the important means of preventing 
the formation of bed-sores. 

The capacity of the organs of assimilation becomes im- 
paired ; the food received into the system fails to renovate 
the wasting tissues ; the adipose which has been stored up 
during the preceding period, and which is of a coarse and 
flabby character, is now rapidly absorbed, and the patient 
daily becomes thinner in flesh, notwithstanding the enor- 
mous amount of food used. Indeed, the quantity of food 
wanted by some patients is phenomenal. Doubtless the 
craving for it is due to the irritation of the vagus at or in 
the vicinity of its origin. 

The vaso-motor disturbances become much more fre- 



502 LECTURES ON MENTAL DISEASES. 

quent during the period of decay. Epileptiform seizures, 
as has already been remarked, not infrequently usher in 
this period. This is especially noticeable, as the more 
active mental symptoms have disappeared, and the friends 
have begun to indulge in the possible hope of at least 
a partial recovery. These attacks generally leave the 
patient, after each successive experience, with an increase 
of paralysis and enfeeblement of mind. 

The degree of severity of these seizures varies very 
greatly in different cases, in some affecting the face, or one 
side of it and the arm of the corresponding side, and also 
the leg, in others only one or more groups of muscles, 
while in others still they will resemble a true epileptic con- 
vulsion, from the immediate effects of which the patient 
never recovers. A case of this character occurred in the 
Retreat a few months prior to this writing. In fact, while 
the seizures are of a milder character in general paresis 
than in true epilepsy, yet there exists no distinctly diag- 
nostic difference. 

Several of these convulsive seizures, of either the milder 
or of the more severe type, may occur one after another, 
and the patient may continue many hours in an uncon- 
scious state ; the face is livid or dark with venous con- 
gestion ; the respiration is irregular, labored, imperfect, and 
attended with a congested condition of the lower and pos- 
terior portions of the lungs. In other cases the convulsions 
are so limited in range and severity that the patient remains 
wholly or partially conscious all the while, and appears to 
recover from the immediate effects in a short time. 

There was a patient in the Retreat, five years prior to 
this writing, in whom the muscular spasm usually began in 
the left hand and traveled up the arm to the shoulder, and 
from thence down the side to the corresponding leg and 



GENERAL PARESIS. 503 

foot. The whole side then remained in a mildly convulsed 
condition during several hours, after which the convulsions 
gradually subsided. They did not cause the patient much 
pain, and frequently the consciousness was unimpaired, and 
he apparently understood what was addressed to him dur- 
ing the earlier period of the seizure, as indicated by the 
expression of the face. He was aphasic during the attack, 
and after the whole side became compromised he would 
give no sign of being conscious. The face and scalp 
became flushed, but there was no difference in the size of 
the pupils. Anaesthesia and partial or total paralysis of the 
side affected usually existed for several hours after the 
spasm had ceased. The patient lived about one year after 
the commencement of this unusual form of spasm. Before 
death both sides of the body became affected during each 
attack. The total number of attacks which he experienced 
was very great, and they extended over a period of two 
years before he finally died from their exhaustive effects. 

These seizures not only tend to become more frequent 
toward the close of life, but often change in character. 
From being epileptiform they may become apoplectiform, 
and vice versa. The change from the latter form to the 
former is said, however, to occur only when the apoplecti- 
form has existed at an early period of the disease. I have 
never observed this latter change of character in any of the 
cases which have come under my observation. 

The apoplectiform seizures are more likely to occur in 
cases in which vertigo, flushings of the face, and headaches 
are complained of. They are frequently preceded by periods 
of sleeplessness, restlessness, and sometimes by maniacal 
attacks. They are attended with increase of temperature, 
congested state of the vessels of the face and scalp, dila- 
tation of the pupils, turning of the head to one side or the 



504 LECTURES ON MENTAL DISEASES. 

other, with noisy breathing, and often with local paralysis 
or hemiplegia. 

They are generally succeeded by a condition of hebetude 
or partial lethargy, which may continue for several hours or 
days. There is also a partially anaesthetic condition of the 
system, and the patient is insensitive to his surroundings, 
noises do not disturb him, and he is indifferent as to the 
character or taste of his food and drink, which he often 
finds a difficulty in swallowing during several days suc- 
ceeding an attack. 

The apoplectiform attacks are not infrequently followed 
by hemiplegia, which is usually transient ; when such 
attacks recur the same muscles are usually affected in each 
attack. 

Baillarger, Mickle, Spitzka, and others have drawn atten- 
tion to a form of acute bed-sores which appear after the 
experience of epileptiform or apoplectiform attacks. They 
develop quite rapidly, are much more persistent and severe 
in character than the sores which form on certain portions 
of the body simply from the failure of nutrition in the parts 
affected and from the frequent discharge of urine in bed. 
Without doubt they are due to trophic causes. On the 
reddened surface, which may appear over the lower por- 
tions of the spine or sacrum, the skin becomes of a dark 
hue, is swollen and turgid, and within a short time a slough 
of the integument occurs, while the tissues underneath are 
of a livid or dark color. A dark sanious discharge appears, 
and if it is not carefully absorbed soon burrows its way 
along the muscles and their sheaths, and down to the 
periosteum of the sacrum and ilia, and sometimes into the 
spinal canal. The edges of the ulcer are of a dirty white 
or ashen color, and are quite insensible to pressure or the 
knife. These so-called acute bed-sores seem to be quite 



GENERAL PARESIS. 505 

identical in appearance and behavior with those which I 
have often seen in wounded soldiers during the late War of 
the Rebellion, who had been long confined in hospitals and 
had become scorbutic. 

In my own experience epileptiform seizures, of one form 
or other, have proved more frequently the cause of death 
than any other. It may occur directly from the severity of 
the convulsion, which exhausts the vital energies of the 
system, or it may come indirectly from disease of the lungs, 
which has developed from the congested state that was a 
result of the spasm ; or, again, from the development of a 
comatose state, from which the patient never recovers, and 
which is probably due to ruptures of the capillaries of the 
brain and consequent effusions. 

Bone fractures are more common in general paresis 
than in other forms of insanity. This may be due to im- 
pairment of nerve energy, which prevents the patient from 
responding to the necessity of guarding himself when in 
danger. He is certainly less sensitive to the effects of 
blows, bruises, and falls, and yet is much more liable to 
receive them, especially during periods of excitement. 
There may also in some cases exist an abnormal brittleness 
of the bone texture, due to absorption of the organic con- 
stituents. Fractures of the ribs are more frequent than of 
other bones. Cases are reported in which post-mortems 
have revealed the fractures of several ribs. 

The following case, which I take from my record, will 
illustrate the ending of the third stage of general paresis. 
J. E. J., age forty-four. This has been one of the typical 
cases of the disease, and was brought to the Retreat in the 
initial stage, has passed through the general conditions of 
that and the pronounced stage, and now presents those of 
the final one. He is no longer able to walk or even to 
43 



$C>6 LECTURES ON MENTAL DISEASES. 

stand, but lies in bed in the position in which he may be 
placed, being barely able to turn his body unassisted. Two 
months since he could walk about the halls and grounds, 
though with difficulty, and with a very staggering gait, 
stammering out that he had a large farm in Maryland with 
three hundred and sixty-five acres, and five hundred horses, 
and promised another paralytic, who was with him, a pair 
of splendid black horses with harness and corn to feed 
them, also that he would raise his father who had been 
dead many years, to life ; said he had invented a steamer 
which would steam to Germany and back in four days, and 
another which would go around the world in a week; that 
he was the strongest man in the world, and could lift 
175,000 pounds, was six feet and nine inches high, etc., etc.; 
but now he is unable to articulate more than a word or two 
at a time, his flesh is fast wasting, he swallows with diffi- 
culty, and is fed chiefly with liquid food ; he defecates and 
urinates unconsciously in bed, but the expression of good 
feeling still lingers on his face, and he makes no sign of 
complaint and has no want to utter ; when addressed he 
sometimes tries to reply, and even to smile a recognition, 
but does not succeed, and the semi-flaccid muscles of the 
mouth and face fail in their effort of movement. Only by 
the most careful attention can we prevent the formation of 
bed-sores. The system will assimilate less and less of 
nourishment, and become even thinner than at present, 
unless the drama shall soon end by a paralysis of the 
muscles of deglutition. 



LKCTCJRK XXVIII. 



GENERAL PARESIS. (Concluded.) 

Remissions — Duration of — Relapses — A Case — Duration of Disease ; Average 
from Three to Four Years — Diagnosis — Characteristic Symptoms — Im- 
portance of Physical Symptoms in Determining Doubtful Cases — These 
May Precede or Follow Mental Symptoms — Maniacal State of Alcoholism 
— Chronic Lead Poisoning — Morbid Anatomy — The Whole Cerebro-Spinal 
and Sympathetic Systems Affected — Diminution in Volume of Brain — 
Adhesion of the Pia to the Gyri — Disease of Vessels and Nerve-cells — 
" Spider-like" Cells — Ventricles — Spinal Cord — Treatment — Prognosis — 
Importance of Early Treatment and of Removal from Home to an Insti- 
tution — Medication — Bromides — Tonics — Laxatives — Hypnotics — Lo- 
tions — Water-bed, etc. 

Remissions. — We have now traced the more pronounced 
symptoms of general paresis, both mental and physical, in 
the order of sequence, which is more often observed. 
There are, however, some cases which are exceptions to 
this course. The involution of the more active form of 
mental symptoms occurs and the motor signs also largely 
disappear. Whatever indications of the disease still 
remain consist in a less degree of mental vigor than is 
normal to the individual, rather than a dementia, and some 
traces of incoordination in muscles or groups of muscles. 
The patient regards himself as entirely recovered and quite 
able to undertake the execution of any plan or project 
which his friends have suggested or proposed for him. 
The memory and power of attention during longer periods 

507 



508 LECTURES ON MENTAL DISEASES. 

have improved ; he converses more intelligently and point- 
edly upon subjects introduced, and seems to have regained 
in some degree, at least, the ability to appreciate the force 
of any objections to plans suggested. The friends, there- 
fore, insist that the patient has recovered, when it is per- 
fectly manifest to the expert that such a condition would 
not continue a single month, or perhaps a single week, out- 
side of an asylum. 

There are other cases, however, in which the remissions 
become quite perfect, and all, or nearly all, the symptoms 
are in abeyance. Dr. Henry M. Hurd has reported a case 
of such remission after the patient had passed through the 
experience of a large carbuncle located over the cervical 
vertebrae. Dr. Sankey has reported a case of apparent 
recovery in which the patient remained well about sixteen 
months. Many others have reported similar cases. They 
occur more frequently after the patient has experienced a 
fracture, had boils or a carbuncle, or some form of inter- 
current disease. 

It would be a mistake to Speedily remove such patients, 
whether the remission be partial or entire, from the care 
and supervision which can be had only in some asylurfl or 
home especially arranged for them. The friction incident to 
everyday life, with the attending necessity of self-control, 
even in the most favorable circumstances, entails a vastly 
greater strain upon the mind than a life wholly freed from 
care and responsibility. Besides, it is of the first import- 
ance that such cases should be constantly under medical 
observation, and in the majority of cases receive medical 
treatment for a long period after the advent of a remission. 
The more favorable the environments and care, other con- 
ditions being auspicious, the longer we may expect the 
remission to continue. 



GENERAL PARESIS. 5O9 

Still, the progress of the disease will again appear sooner 
or later, in the vast majority of such cases, even after the 
lapse of years, and not unfrequently is ushered in by an epi- 
leptiform seizure or an outburst of maniacal excitement, after 
which the course of the disease is generally more rapid than 
before. I say generally, because cases are on record in which 
there have occurred several such remissions. Cases also 
sometimes occur in which remissions relate chiefly to the 
motor symptoms, while the mental symptoms remain 
unmodified. 

Only one such case has been under my observation. 
The physical symptoms, when again they appear, develop 
rapidly and follow the usual order of sequence. 

In 1879 a case was under my care in which the symptoms 
were characterized by expansive ideas and projects, great 
restlessness, and some excitement, with moral defect, while 
the physical symptoms were quite obscure. After three 
months there occurred so far an abatement of the condi- 
tions that some of the friends insisted that a mistake had 
been made in the diagnosis, and that he did not longer 
require the seclusion and care of an asylum. He was 
accordingly removed and set at liberty. I am unable to 
report how long he remained unrestrained, but he very 
soon plunged into a life of speculation, became indecent in 
language, and most lascivious in conduct, and died in less 
than three years, of general paresis. 

Duration. — One of the questions which are always, 
or nearly always, addressed, to the physician is, " How long 
is the patient likely to live ? " A reply can be given only 
in a very general manner. One can be based upon the 
experience of the physician, or upon that -of institutions. 
The experience of physicians and even that of different 
institutions will differ quite largely as to length of time. 



5IO LECTURES ON MENTAL DISEASES. 

In some it will be 1 5 months for men and 2 1 months for 
women, while in others it will be 20 months for men and 
28 or 30 for women. 

It will be necessary also to bear in mind that there exist 
frequent exceptions to any period of time. While some 
patients die within three or four months after they are 
placed under restraint, others live on from four to six 
years. In forming an opinion as to any given case, it will 
be important to take into consideration the past history of 
the patient in reference to occupation, habits in the use 
of alcohol, sleep, and heredity. Of these four factors, 
the last one will prove to be the most influential in deter- 
mining the period of life in cases of a typical character. 
The patient may, however, die from the immediate effects 
of repeated epileptiform or apoplectiform seizures, which, 
of course, cannot beforehand be anticipated in any given 
case, or he may die suddenly from accidental suffocation in 
consequence of paresis of the pharyngeal muscles. After 
the symptoms have become pronounced, patients usually 
average from one to three or four years. 

Diagnosis. — The diagnosis of typical cases of general 
paresis, or those which are usually found in the halls of 
asylums, is not difficult. This arises from the fact that 
usually the characteristic physical symptoms are present, 
such as muscular weakness, incoordination of gait, fibrillar 
twitching of the surface of the tongue and of the smaller 
muscles of the hands, local anaesthesias, epileptiform and 
apoplectiform seizures, etc. Where these physical symp- 
toms are present it will be safe to diagnose the case as one 
of general paresis, even in the absence of the typical mental 
symptoms, such as the peculiar mental facility, loss of 
memory, expansive delusions, gradual deterioration, and 



GENERAL PARESIS. 5 I I 

dementia. The presence of both physical and mental 
symptoms renders the diagnosis easy, and if these are once 
observed they will not be easily forgotten. 

There are also other cases in which, though these somatic 
and psychic symptoms have not yet become fully devel- 
oped, and are not apparent at the first examination, yet 
the diagnosis may not be doubtful. Upon repeated obser- 
vation it will be found that there exists a change in mental, 
and even in the physical habits of the patient, and that 
this change is of such a nature that it points toward a 
future development of the usual conditions attending 
general paresis. This will appear in the loss of moral 
tone, a commission of some act which is foreign to the 
individual's past history, indisposition or inability to attend 
to ordinary avocations, with increase of motor activity, 
cephalalgia, and insomnia. While such symptoms alone 
are not sufficient to justify a positive diagnosis, yet in the 
absence of others, which would indicate other forms of 
insanity, they may be regarded as sufficient to justify a 
probable one. 

But there are other cases in which the differential 
diagnosis may present difficulties, even to the experienced 
alienist. Among them may be mentioned those in which 
the mental symptoms predominate and assume a very 
acute form without correspondingly well-marked somatic 
symptoms. The states of mental excitement or depression 
which at times appear in general paresis do not at first 
view essentially differ in character from those which exist 
in mania, when very acute and of an exalted character, or 
from those of melancholia, when accompanied with delu- 
sions of persecution, and may entirely obscure the latter 
class of symptoms. Moreover, these mental states may 
appear at different times in the same patient, which will 



512 LECTURES ON MENTAL DISEASES. 

tend still further to obscure the case. I have already 
referred to such, or a similar case (page 482), in which, 
during periods of excitement, and even in conditions of 
exaltation, the somatic symptoms, which at the best were 
very slightly developed, seemed to be wholly in abeyance. 
He was examined by competent experts frequently, and 
yet without their being certain that it was a case of general 
paresis, though it proved to be one. Such cases require 
repeated examinations, and when in different mental states. 
A history of the initial period of the disorder, its relation 
to heredity, social and business habits of life, slight 
dementia and failure of memory, attacks in which there 
may have been vertigo or loss of consciousness for short 
periods, will prove to be of essential service in clearing up 
the diagnosis. Reliance may also be had upon any slightly 
developed physical symptoms which may appear during 
periods when the patient is comparatively free from excite- 
ment, and especially after prolonged exercise, such as 
hesitation in speaking, an occasional slurring of syllables 
in a word, or in twitchings of the orbicular muscles, and a 
change in gait. In the total absence, however, of any such 
indications, it will be necessary to defer the diagnosis for 
further consideration, and this may be for several months. 

It may be added that a diagnosis in such cases is often 
of the first importance, as it very likely will determine the 
necessity, or otherwise, of adopting the requisite measures 
as to the care or disposal of property. On the one hand, 
if the case is one of acute or congestive mania or melancholia, 
there would exist a reasonable probability of a recovery 
under treatment for a few months, and no such measures 
would be necessary or desirable ; on the other hand, if the 
case is one of general paresis, the certainty of a fatal ter- 
mination at no distant day might necessitate a different 



GENERAL PARESIS. 513 

course of legal procedure, in order to protect property and 
family interests. 

Again, we occasionally meet with cases in which the 
conditions are reversed, and the physical symptoms are 
pronounced, while the mental are obscure. It is not many 
years since it was a much debated question whether the 
physical ever preceded the mental symptoms in the order 
of appearance. German authors advocated the affirmative 
of this question, while many English writers claimed that 
although there may be neither excitement nor marked 
depression, yet it is always true that patients exhibit 
evidence of such mental weakness and loss of tone as 
uniformly precedes the characteristic dementia of general 
paresis, and that when no change in the mental character 
is to be found, the cases are not genuine. There can be 
little doubt, however, that in some cases when the disease 
commences in the cord, and gradually proceeds up to the 
brain, the mental symptoms may not be apparent until 
several months after the inception of the disease. The case 
mentioned on page 476 was one in point. 

The disease began in the cord, and she was regarded as 
having locomotor ataxia, until the mental symptoms 
appeared quite suddenly in the form of excitement and 
delusions of grandeur. In recalling the history of the case 
afterward, neither the physician nor the husband could 
remember anything whatever unusual in the character of 
mental activities for more than a year after the motor 
symptoms appeared, but did recollect that she gave 
evidence of mental weakness for some time prior to 
the appearance of the more marked mental symptoms. 
It will be necessary to defer a diagnosis in such cases 
until some evidence may be forthcoming of a mental 
character. 
44 



514 LECTURES ON MENTAL DISEASES. 

The maniacal state, which sometimes is one of the 
sequelae of prolonged alcoholism, may be attended with a 
disturbance of the circulation of the brain, and also with 
other conditions which resemble those of general paresis, 
such as headache, hebetude, enfeeblement of all the intel- 
lectual faculties, exalted and expansive delusions, etc. As 
alcoholism is one of the frequent causes of general paresis, 
a provisional diagnosis may be suggested and further obser- 
vation secured. Abstinence from the use of alcohol in 
cases of simple alcoholism is nearly always soon followed by 
a marked improvement in these symptoms, which will not 
be the case if general paresis is present. For other points 
of differential diagnosis., as between general paresis and 
alcoholic paresis, reference is made to the chapter on the 
latter disorder. 

General paresis, when attended with protracted periods 
of silence and stupor, may usually be differentiated from 
melancholia attonita by the somatic symptoms of the 
former, and by the slight differences usually present in the 
stuporous condition, as presented in the two diseases, such 
as occasional indications of a wider range of thought, the 
occurrence of short periods during which the general paretic 
will talk, and also a less measure of mental suffering, as 
evinced in the lineaments of the countenance when alone. 

The dementia of general paresis can be differentiated 
from primary dementia, and dementia secondary to acute 
attacks of mania, usually by means of the history of the 
case, or, in the absence of this, by the presence of the 
physical signs. 

Repeated and severe epileptic seizures are sometimes 
followed by symptoms which resemble those of general 
paresis, such as incoordination of ideas, loss of memory, 
inability to appreciate the environment, failure of attention, 



GENERAL PARESIS. ' 5 1 5 

and a decided weakening of all the intellectual faculties. 
There may also exist a difficulty in the articulation of certain 
words, or amnesic aphasia, inequality of the pupils, and 
failure in accomplishing all the finer movements of the 
hands and fingers. These symptoms, however, when 
present after epileptic attacks, do not continue* many days 
after the attacks have ceased, and no such mental history 
as that which pertains to general paresis follows. A 
difference in the character of the seizures in the two 
diseases is generally observable ; the general paretic rarely 
experiences a fully developed epileptic attack. It is usually 
characterized as epileptiform. 

Chronic lead poisoning is sometimes attended with 
symptoms of local paresis, and general weakness of the 
whole muscular system, embarrassment and hesitation in 
conversation, and inability to use one or both arms except 
imperfectly. As characteristic of such cases, how 7 ever, 
there will usually be present certain other symptoms which 
are not found in general paresis, such as the blue line on 
the gums, nausea and vomiting, and frequently some dis- 
coloration of the skin. There will also be an absence of 
the history of general paresis. 

Morbid Anatomy. — It will not be my purpose to even 
enumerate any considerable number of the many morbid 
changes which have been found by different author- 
ities after death in general paresis. They are legion in 
number, and are found in every part of the cerebro-spinal 
and sympathetic systems, and in this respect correspond to 
the very great variety of symptoms which have existed 
during life. Moreover, authorities are not yet agreed as to 
the nature of some of these changes, which are demonstrated 
only by the means of a microscope, — that is, whether they 
are the result of a true inflammatory process, or, on the 



5 l6 LECTURES ON MENTAL DISEASES. 

other hand, are due to merely degenerative processes 
originating from some other source of irritation. For our 
present purpose it will be necessary to mention only some 
of the more obvious and gross morbid lesions, merely 
observing in passing that in order to reach an agreement 
as to the trile nature of the initial morbid change, it may 
be important to attach a definite meaning to the term 
inflammatory process. 

One of the first changes to be observed in the brain of 
the general paretic who has not died in the early stages of 
the disease, and which is readily perceived when it becomes 
exposed, is its apparent diminution in volume. The solid 
substance no longer fills the whole interior of the skull, 
but appears shrunken, as if the convolutions had been 
pressed upon each other and the sulci between the convolu- 
tions are much wider than in health. This diminution is not 
only apparent ; it is actual, and attended with a compen- 
satory serous effusion. While it is true that the brains of 
nearly all patients who have died insane, and who have 
lived in this state during many years, are diminished in 
weight, yet those of general paretics are especially so, the 
amount of shrinking in the tissue averaging from three to 
five ounces. The cerebellum participates in this shrinkage 
to a less extent than the cerebrum. 

Another of the most constant of the morbid conditions 
which are apparent to the unaided vision, and which has 
been described by writers since 'the disease became differ- 
entiated, relates to and consists in adhesions of the pia 
mater to the summits of the gyri. When the adherent 
membrane becomes detached, portions of the gyri remain 
adherent to the under surface of it, and the remaining por- 
tions present an irregularly broken or torn appearance of a 
dark reddish or brick-dust color. This adhesion, which is 



GENERAL PARESIS. 517 

confined to the eminences of the cortex, and does not dip 
down into the sulci, has been found in from seventy to 
ninety per cent, of all cases, though in some it exists on 
only a slight extent of surface. 

It has been thought by some to indicate the inflamma- 
tory origin of the disease, while others have claimed that the 
fact of its being limited to the eminences of the gyri, and 
not following down the membrane into the sulci, was an 
evidence to the contrary; and have suggested that these 
adhesions are due primarily to the pressure ^to which 
the points invaded have been exposed by the congested 
condition of the brain prior to the period of pronounced 
and degenerative symptoms. No special regularity of the 
area over which the adhesion may extend appears to exist, 
but according to Mickle it is found in the larger per cent, 
of cases on the superior frontal gyrus. 

It has remained for more recent observers not only to 
exhibit, by means of the microscope and the improved 
methods for preparing the tissues for examination, the 
presence of this morbid process in the more superficial 
tissues, but to trace its earliest invasion of the sheaths of 
the vessels of the pia mater. The coats of these vessels 
become paralyzed to some extent and permit the exudation 
of serum into the spaces between the pia and arachnoid 
membranes. The small connective rods in this space, 
which in a normal condition of the membranes remain lax, 
become tense and distended, and during a later stage of 
the disease, when the changes which occur in the cortex 
have resulted in degenerative processes and atrophy, this 
exudation becomes much more abundant, especially in the 
sulci which separate the convolutions. It also exerts a 
pressure upon the summits of the gyri, which accounts for 
their pinched and narrowed post-mortem appearance. 



5 18 LECTURES ON MENTAL DISEASES. 

This diminution of breadth in the summits of the gyri 
removes the normal support of the vessels of the pia, and 
they not only exude serum, but, as the disordered process 
extends, their coats yield, resulting in minute aneurisms or 
entirely give way, and thus cause minute hemorrhages. 
These hemorrhages may eventuate in the slight apoplectic 
seizures which sometimes occur. They seem to be quite 
identical with the minute serous exudations and hemor- 
rhages which occur at times in the senile brain, and are 
due to the extension of degenerative rather than inflam- 
matory processes. 

But this morbid process, which has its inception in the 
cells of the vessels of the membrane, does not stop there 
nor in the elements which lie in juxtaposition to them. It 
gradually extends to the different cortical -layers, attacks 
the pyramidal cells, and causes the ultimate disappearance 
of many of them, leaving little remaining of their contents 
except traces of granular material. In place of them, or 
nearly simultaneously with their disappearance, a cell of 
another form and function appears. These have been termed 
the " spider-like cells," and appear to increase in proportion 
as the degenerative element disappears in consequence of 
the progress of the disease. According to Dr. W. Bevan 
Lewis,* they "become the 'phagocytes' or scavengers 
of the tissues ; live, thrive, and multiply upon the degen- 
erating protoplasmic masses of nerve-cells and their exten- 
sions and all effete material lying in their neighborhood, 
until it is ultimately appropriated to their use." 

In some cases the cortical layer can be easily detached 
from the tissues beneath and even may itself be divided 
more or less regularly into two or more layers. 

* "Text-Book of Mental Diseases," by W. Bevan Lewis, p. 500. 



GENERAL PARESIS. 5 19 

As the morbid process extends its invasion into the 
normal vascular and cellular structures, there results an 
increase of the connective tissue as a sequence, which 
appears to take the place of the former. 

The ventricles are frequently found to be much diseased. 
The lining membrane is thickened and rough in conse- 
quence of the irregular growth of the tissue, presenting in 
some cases a greyish appearance, while in others are found 
distinct nodules and eminences like small warts. 

The spinal cord is found to be implicated by no means 
to the same extent in all cases. We should infer this from 
the absence, presence, or prominence of certain symptoms 
during life. In some cases spinal symptoms are almost 
wholly absent, especially during the early periods of the 
disease, except it may be a degree of local anaesthesia and 
diminution of the reflexes, while in some others they are 
wholly absent. In others they are the first in the order of 
appearance and furnish the most notable indications. This 
difference, of course, depends upon the presence or absence 
of lesions in the cord, and when present, the parts are affected 
by sclerosis, whether it be the posterior or the lateral 
columns, or both. 

The membranes of the cord, especially the pia mater, 
become thickened and opaque, and granulations may appear, 
and also rough patches on them. The cord also becomes 
lessened in size in some cases, while in others it becomes 
softened and surrounded with serum. The degeneration 
of the posterior columns is generally the most marked, 
especially in the lower portions. 

In those cases in which the patients gradually waste 
away and a profound dementia occurs, nearly all the 
nervous tissues represented by the organs of special 



520 LECTURES ON MENTAL DISEASES. 

sense and the sympathetic ganglia are found to be im- 
plicated.* 

Treatment. — The alienist in charge of an institution, or 
in consulting practice, is rarely called to examine and pre- 
scribe for a general paretic until after the disease has 
become so far advanced as to be beyond the effect of reme- 
dial medicines, except as they may prove to be palliative. 

The few cases which have been reported as recoveries after 
being admitted to an institution are, at the least, somewhat 
doubtful, and if accepted as genuine would only prove the 
general rule .that recoveries do not occur. Indeed, when 
the symptoms, physical and mental, have become so far de- 
veloped as to render a diagnosis certain, already the pathway 
on which the patient must travel, and even the length of time 
during which he will very likely be in passing over it, are 
pretty accurately discernible. On that highway he sees in- 
scribed in the plainest of letters — " Facile deccnsus averrii" ; 
and also " Nulla vestigia rctrorsum" If ever in the previous 
history of the case there had existed a period during which 
restorative treatment might have been of avail, that period 
has now passed, and, therefore, whatever he may be able 
to suggest will resolve itself largely into nursing and care. 

The question now arises whether there may not have 
existed a period prior to the development of these charac- 
teristic physical and mental symptoms when, if the case 
had been understood, treatment might not have sufficed 
to avert the entrance on that fatal pathway. If the import- 
ance of the initial conditions, attended with headache, de- 
pression, languor, loss of interest and satisfaction in the 

* For a more extended study of the microscopic appearances of the brain 
and spinal cord in general paresis, I must refer to the treatises of Spitzka, in 
our own country, and to Lewis, Mickle, and Voisin, abroad. 



GENERAL PARESIS. 52 [ 

pursuit ol usual avocations, indisposition to read or occupy 
the mind, especially with what has formerly been of inter- 
est, and the development of a kind of motiveless activity, — 
if, when these indications began to appear they had been 
rightly interpreted and an efficient system of treatment 
had become instituted, might not the system have 
responded, and the subsequent development of the dis- 
ease been averted ? The late Dr. Tyler was very posi- 
tive in the belief that he had succeeded in arresting the 
development of the disease. Others have been equally 
confident of the practicability of doing so, or at least of 
postponing its evolution for an indefinite period. But 
whether it be true or not, there certainly exists no inherent 
improbability in the view that while the morbid process has 
proceeded only so far as simply to derange the physiologi- 
cal function of the nerve element, or lessen it, and before it 
has proceeded so far as to destroy it, measures of treatment 
may prove efficient in arresting further progress, and in 
restoring these elements again to their normal state of 
activity. 

It may be added that if such results follow treatment 
instituted for averting the development of other forms of 
mental or nervous diseases during the initial stages, we 
may, at least, expect it will do so in general paresis. But 
evidently the great difficulty will be in appreciating and 
determining the significance of the somewhat obscure and 
doubtful symptoms, inasmuch as they may appear in cases 
which, without treatment, never eventuate in general pare- 
sis. At this stage, the history of the individual as to 
heredity, habits of life, occupation, mental strain, loss of 
sleep and morals, will prove an important factor in deter- 
mining the probable prospect and the course to be pur- 
sued. Assuming, then, such a case with an unfavorable 



522 LECTURES ON MENTAL DISEASES. 

history, what measures will be most likely to prove effi- 
cient in averting the threatened oncoming of disease ? 

The first, and a very essential one, will be a thorough 
change as to those conditions and habits of life which have 
appeared to be efficient in producing the threatened attack. 
For this purpose some new form of light employment may 
be suggested, or travel, diversion of the mind into other 
channels of thought, regularity of habits as to sleep and 
exercise, friction applied to the body and extremities with 
an effort to improve the circulation of the latter, regularity 
in the use of a simple and nutritious diet without wine or 
stimulants of any kind, with an abandonment of excesses 
in every form, if any have existed. If the patient has been 
accustomed to an intellectual occupation, this should be 
abandoned for the time being, and every source of anxiety, 
worry, and care avoided. Absence from home, and travel 
with a judicious companion, and visits to new scenes and 
places which may present enough of interest and novelty 
to divert and occupy the mind, will prove to be an efficient 
means of improvement. In short, the business man, the 
lawyer, the politician, the physician, must each seek for 
such diversion and change as will probably prove most 
conducive in withdrawing them from former habits of 
thought and modes of life, at least so far as may relate to 
care, anxiety, and responsibility. 

An absence from family life and city surroundings, and 
life out-of-doors in some favorable climate, will be advis- 
able, at least during several months. All subjects of con- 
versation or discussion which will be likely to develop 
unusual interest or difference of opinion should be most 
studiously avoided, and yet in such a manner as not to 
attract the attention of the patient. Indeed, the benefit to 
be secured from the course of proceeding outlined above 



GENERAL PARESIS. 523 

will depend largely upon the skill and perseverance of the 
attendants and friends who may be about and have the care 
of the patient. Boundless patience, tact, and devotion will 
be called into requisition, while the physician should seek 
to restore disordered secretions, relieve congestions, and 
calm all nervous agitation and anxiety. 

If at any period the therapeutical agencies are to be of 
any value in arresting the progress of the disease, it would 
appear to be during the initial period, and the earlier the 
better. From the fact that a few cases have been reported 
in which the disease has been arrested, or at least its evolu- 
tion postponed, by the appearance of a carbuncle, or some 
form of intercurrent disease, it would appear reasonable to 
expect benefit from the use of the actual cautery, or from 
the long-continued application of cupping glasses or a 
seton at the nape of the neck. The |iodide of potassium, 
with such medicines as may be indicated for the appetite 
and to secure sleep, will be in order. 

The bromide of sodium and ammonium may be given to 
quiet excitability and restlessness and procure sleep. The 
iodide of potassium should be used freely in case there exists 
any ground for a supposed syphilitic basis of the disease. 
It may be anticipated that by the early recognition of the 
disease, and by instituting at once some such course of 
management as is outlined above, favorable results may pro- 
bably be secured in a few cases. 

It should, however, be borne in mind that what has been 
suggested is of importance only in the very earliest portion 
of the initial period. If the case has progressed so far that 
the inherent energizing capacity of the cells of the grey 
matter, upon which the process of mentalization depends, 
has become largely impaired, there will be no longer hope 
of restoring it to a condition of normal activity. As the 



524 LECTURES ON MENTAL DISEASES. 

elements of these cells are the highest and most complex 
development of the system, so they are the most sensitive 
in response to unfavorable influences, and are the least 
amenable to restorative treatment. 

After the disorder has become established, and while the 
patient is still restless and anxious to travel, advice will 
often be requested by friends as to the desirability of his 
doing so. In reply it may be stated that generally the 
more quiet and secluded patients can be kept, the less will 
become the danger attending excitement and the exhibition 
of passions. Nor should patients be retained at home with a 
view of treatment there. They will be likely to still regard 
themselves as masters in their own houses and decline to 
place themselves under such restrictions as to conduct, 
food, and medicine as may be necessary. Another most 
important reason for placing such patients under restraint 
arises from the peculiar character of their delusions. This 
not unfrequently leads to the squandering of property in 
the most reckless manner and to entering upon large busi- 
ness enterprises which lead to ruin. No class of insane 
patients are so likely to bring financial trouble upon their 
families before measures of restraint are instituted as gen- 
eral paretics. 

General paretics, when under the influence of delusions 
of importance, grandeur, and great wealth, if repressed often 
become domineering and dangerous. This is true while 
they are under the protection of strangers, and much more 
frequently the case when the repression is instituted by old 
friends or the members of their own families. Seclusion, 
therefore, becomes necessary for short periods or during 
the continuance of the furious excitement. There is a 
young man at the time of this writing in the Retreat who 
has experienced a period of excitement once and sometimes 



GENERAL PARESIS. 525 

twice a day during the past three weeks. During the con- 
tinuance of these attacks, which come on very suddenly, 
he throws himself upon his attendants, with whom he is on 
very friendly terms at other times, in the most violent man- 
ner and it requires two or three strong men to restrain him 
until he can be secluded. He seems to have no remem- 
brance of what has occurred at such times after the attacks 
have passed. 

Again, the disease may assume the form of depression, 
and patients become suicidal and refuse to take food. 
When such is the case the procedure necessary to admin- 
ister it, if undertaken at home, becomes most unsatisfactory 
and distressing to all concerned. 

It may be taken as a rule, therefore, that general paretics 
should be removed to some institution as soon as the dis- 
ease is determined, where they can be placed under the 
immediate care of physicians and trained nurses who are 
entire strangers to them, and by whom they can generally 
be much more easily influenced than by their own relatives, 
and where quiet and skillful moral management will be 
accorded them. 

Medication should have relation to modifying or reliev- 
ing the conditions which have already been described. 
Cases attended with cerebral hyperaemia, congestive attacks, 
and headaches may be treated by cold in the form of ice 
bags applied to the head, cold baths, and at times with the 
prolonged bath. The latter should be used with great 
care and always supervised by the physician. Dry cupping 
and the application of mustard to the nape and feet may be 
employed with advantage. Of medicines the bromides are 
the most effective in the form of a combination of two parts 
of potassium to one each of sodium and ammonium. I 
have never had experience with the heroic measures which 



526 LECTURES ON MENTAL DISEASES. 

have been recommended by some authorities, such as 
bleedings, blisters, and moxas, nor with the practice of 
creating and continuing an open and suppurating sore upon 
the neck or back. Patients who have been under my care 
have not generally been in such a physical state as to war- 
rant such measures of treatment. If they are ever to be 
adopted it seems to me that the time for their use is at the 
earliest indications of approaching disease rather than when 
it has become fully pronounced. 

In those cases in which the bowels do not move daily 
simple purgatives may be given at bed-time, or a move- 
ment may be secured by the use of an enema. It is especi- 
ally important that a costive state of the bowels be avoided, 
as this is one of the most efficient causes in provoking 
epileptiform seizures. 

I have already referred to the use of the bromides and 
iodides during the initial period. They may also be used 
either singly or combined, in moderate doses, for the pur- 
pose of relieving sexual excitement, restlessness, insomnia, 
and congestive attacks. They may sometimes be advan- 
tageously combined with digitalis or cannabis indica. 
When the restlessness becomes very great and the patient 
is unable to sleep we may give either hyoscine, sulfonal, or 
the hydrate of chloral or paraldehyde. These medicines 
should not be continued generally more than a few nights ; 
if necessary other hypnotics may be substituted for them. 
Cold applied to the head, or a bath, may sometimes prepare 
the patient for being more easily and fully influenced by 
these medicines. The use of opium in any of its forms 
should be avoided. 

For the purpose of preventing both epileptiform and 
apoplectiform seizures it is especially important that the 
diet be carefully arranged. While the food should be of a 



GENERAL PARESIS. ^2J 

highly nutritious character, it should also be easily diges- 
tible and the stomach should never be overloaded ; it is 
better to take a small quantity often. The bromides may 
be given by enema if necessary ; frequent applications of 
cold to the head and sinapisms to the nape and lower 
extremities may be of use. 

The condition of the bladder should be daily observed 
and, in case of paralysis, the urine should be drawn with 
a catheter twice every twenty-four hours. 

Bed-sores sometimes become one of the most trouble- 
some complications during the final stage. Efforts should 
be made to prevent their occurrence by the strictest atten- 
tion to cleanliness and bathing the most exposed parts with 
alcohol and lead lotion. The pelvis may be supported 
upon an air cushion so as to avoid pressure on the most 
sensitive parts. But one of the most efficient preventive 
measures will be the use of the water-bed. This is indeed 
a great boon to the unfortunate and emaciated patient. 
Bandages of soft cotton have been recommended, though I 
have had no experience with their use. 

After the formation of bed-sores they may be treated by 
the frequent application of charcoal, or some other form of 
poultices. The parts should be carefully cleansed after 
their removal with carbolic solution. The permanganate 
of potash may also be of service, and the granulations may 
be stimulated by the application of ointments, etc. 



LEXTTURK XXIX. 



ACUTE DELIRIUM (TYPHOMANIA). POST-FEBRILE 
INSANITY. 

Historical References — The Term Typhomania — Definition —Etiology — Emi- 
gration — Exposure to High Temperature — Physical, Mental, and Alco- 
holic Excesses— Symptoms — Develop Rapidly — Indications of Fatigue — 
Insomnia — Delirium, Character of — Subsides in about Two Weeks, and 
is Succeeded by Conditions of Semi-stupor — Countenance — Pupils — 
Tongue — Intolerance of Food and Drink — Pulse — Circulation — Vesicles 
— Examples — Morbid Anatomy — Diagnosis — Treatment — Post-febrile In- 
sanity — General Remarks on the Delirium of Fevers — Trousseau — 
Delirium in Children — Delirium in Typhoid Fever not of Serious Import 
— Three Forms of Mental Impairment Following Fever — Relative Im- 
portance of Each — ^Etiology — Unwise Treatment of Fevers in Reference 
to Feeding — Symptoms — May be of an Excited or Depressed Type — 
Physical Conditions are those of Anaemia and Perverted Nutrition — Dr. 
Hurd's Twenty-three Cases — Cases Following Surgical Operations — 
Hochwart's Thirty-one Cases Following Eye Operations. — The Thirty-five 
Cases of the Retreat — Prognosis — Generally Favorable — Treatment. 



ACUTE DELIRIUM. 
Dr. Luther V. Bell first directed attention to and pre- 
sented a paper upon this form of mental disease at the 
meeting of the Association of Superintendents of American 
Asylums, in 1849. He described it as a "New Form of 
Disease," which resembled some of the advanced stages of 
mania and fever, and yet so far differed from any described 
form of disease as to render it probable that it had hitherto 
been overlooked. In 1850 a paper was read before the 

528 



ACUTE DELIRIUM. 529 

meeting of the same association by Dr. W. H. Ranney 
upon " Insane Foreigners," in which he alludes to this form 
of disease, as described by Dr. Bell, as one of frequent 
occurrence among emigrants, placing it second in point of 
frequency among those whom he had treated in the asylum 
on Blackwell's Island. He describes it as a " form of dis- 
ease apparently intermediate between mania and typhoid 
fever," but gives it no definite name. In 185 1, Dr. C. H. 
Nichols addressed a letter to the editor of the Journal of 
Insanity, enclosing a short communication from Dr. A. V. 
Williams to himself, in which he (Dr. Williams) gives some 
account of a form of insanity "which in our conversations 
and in my reports I have denominated typhomania, from 
the striking typhoid character of the physical symptoms it 
exhibits and the treatment required for its cure." 

It thus appears that the term typhomania was not that 
of Dr. Bell, but Dr. Williams, and that it was used, at least 
in the earlier history of the disease, from the supposed 
relation it sustained to typhus or typhoid fever. To Dr. 
Bell, however, belongs the honor of first directing attention 
to it, differentiating and describing so fully its symptoms 
and march of progress that subsequent writers have added 
but little additional information in relation to them. This, 
however, could not be said in reference to its morbid 
anatomy, as the modern methods of examination of brain 
tissues were then unknown. While he suspected patho- 
logical changes in the brain from the character of the 
symptoms, he failed to satisfy himself that they existed, 
and Dr. J. B. F. Jackson was equally unable to demonstrate 
such morbid alterations of tissue. The investigations of 
later students have supplied this deficiency, and have more 
fully differentiated it from any form of or connection with 
typhus or typhoid fever. 
45 



530 LECTURES ON MENTAL DISEASES. 

Definition. — Acute delirium is an affection accompanied 
with great mental disorder, a rapid development and course, 
more often than otherwise fatal, and presenting symptoms 
which resemble in a marked degree those attending certain 
very acute cases of typhus, typhoid, and puerperal fevers, 
meningitis, and some degree of intoxication. It is more 
common among females than males. 

^Etiology. — Dr. Ranney was of the opinion that the 
disease was caused more often among immigrants from the 
unfavorable condition attending the passage to this country 
and the disappointments arising during the earlier periods 
after arriving, such as the crowded and poorly ventilated 
rooms occupied on the steamers and failure to secure 
employment, and consequent worry and anxiety. Heredity, 
predisposition to brain disorder, excessive heat, great 
physical, mental, and alcoholic excesses, are all believed 
to hold an important relation as causes. 

Symptoms. — Psychical. — The mental symptoms develop 
much more rapidly than is usually the case in either 
mania or melancholia. Frequently there exists some 
such history as that patients have not been quite well, 
have complained of or have given indications of fatigue, 
lassitude, and an indisposition to pursue usual avocations ; 
have been restless, nervous, and unusually irritable, but 
not enough so to lead to the apprehension of friends or 
themselves. After a short time, perhaps a few days, pain 
in the head becomes pronounced, the patient is unable to 
sleep, and the mind passes quite suddenly into a state of 
acute delirium, which is generally attended by indistinct 
hallucinations of sight. These are not infrequently of a 
frightful character, such as burning buildings, or flames in 
the room, and of blood upon the walls or ceiling, and every 
effort will be made to escape from the dangers and fright- 



ACUTE DELIRIUM. 53 I 

ful si^ht. At other times the hallucinations refer to some 
person supposed to be an enemy who is in pursuit of them 
for the purpose of throwing them from a precipice or into 
the flames, and the patient struggles with desperation to 
escape, until he falls back bathed in perspiration and quite 
exhausted. Hallucinations of hearing are much less fre- 
quent than those of sight, and definite delusions do not appear 
to exist unless those of fear. When apparently free from 
hallucinations and lying upon a bed, the hands are often 
in constant motion, striking each other or at the attendant, 
or the patient is counting off some special number on the 
fingers, or making some childish rhyme, such as one, two, 
three, don't you see, or two, three, four, open the door, etc., 
etc., and then the mind recurs at once to the phantom pano- 
rama, which seems to be ever floating past the mental vision 
with the greatest rapidity and evanescent nature. The flow 
of words addressed to this vision is constant, and constantly 
changes without sequence, coherence, or order. In fact, it 
appears to be almost or quite automatic. 

One of the most constant symptoms during the earlier 
stages of the disease is inability to sleep, and large doses of 
the ordinary soporific medicines have very little effect. In 
the case of females there exists not infrequently a fear, or 
phantom delusion, that they have been foully dealt with 
and are about to be in labor. In the midst of these 
delirous mutterings, however, it is quite possible to gain 
the attention for a moment, and the tongue will be pro- 
truded and an answer given to a question. The patient 
may recognize the physician or attendant, calling them 
by name, and then at once resume the iteration of an 
endless medley of words or sentences, roll the head upon 
the pillow, and the agitation and restlessness become 



532 LECTURES ON MENTAL DISEASES. 

extremely excessive, the patient rolling about the floor or 
rushing about the room unless restrained. 

This general condition of restless delirium continues 
during ten days or two weeks, and then gradually subsides. 
The flow of words ceases, sometimes from inability to 
articulate, and at others apparently from a fading out or a 
diminution of the vividness of the hallucinations of sight. 
The mental function appears to be quite in abeyance, and 
the patient lies unconscious, sleeping several hours a day, 
and never able to comprehend, and much less to answer, 
any questions. 

2d, Physical. — At this period the physical symptoms have 
become quite fully pronounced, having steadily developed 
since the third or fourth day. The face is pinched, anxious, 
and frequently of a dark, dusky hue, especially under the 
eyes, and the general expression is one of fear. The pupils 
may be either contracted or dilated, but are not tolerant of 
light, while the vessels of the conjunctivae are often injected. 
The hands and tongue are tremulous, while the latter is 
brown, and the teeth covered with dark sordes ; the lips 
become dry and cracked, and the throat full of a thick, 
tenacious mucus, so that the patient is unable to swallow 
even fluids without great difficulty. The stomach is intol- 
erant of food and drink, and what is given is soon vomited. 
The pulse is not much above ioo except in fatal cases and 
toward the end ; during the early stages it may be below 
normal, while the extremities are cold and require artificial 
warmth. In the earlier stages the bowels are constipated, 
but later there may be diarrhcea. The action of the heart 
is generally feeble, and in nearly all cases the capillary cir- 
culation is much impeded in consequence of the paralysis 
of the vaso-motor nerves, so that the slightest bruises 
become inflamed or ulcerated. 



ACUTE DELIRIUM. 533 

In a certain proportion of cases, more particularly dur- 
ing the later stages of such as prove fatal, small vesicles 
appear upon certain portions of the body and limbs ; a 
thin, whitish fluid exudes under the cuticle, which soon 
breaks and a dark brown scab is formed, which becomes 
from one-fourth to one-half of an inch in diameter and 
one-sixteenth or two-sixteenths of an inch in thickness. 
These are quite irregularly scattered about the anterior 
surface of the body and limbs, but I have never observed 
either sudamina or petechias. 

Generally there occurs a crisis within two weeks. The 
delirium ceases and a dawning of consciousness returns. 
The stomach becomes more tolerant of food, the pulse less 
frequent, and the temperature normal. The interval which 
has passed is a mental blank, and with surprise patients 
inquire where they are. The cessation of the delirium is 
rarely followed by dementia or delusions, and when it is so, 
according to Dr. Ranney, it is only in cases which have had 
previous attacks of insanity. The recovery is usually 
quite rapid. 

While the above enumeration of symptoms is fairly 
accurate in typical cases of acute delirium, yet it should be 
stated that cases are sometimes seen in which these symp- 
toms appear only in a modified form. They have the 
essential characteristics but do not pass over into their 
fully developed character, and may not do so if patients 
are properly treated from the first, and are otherwise 
favorably conditioned. 

Example I. — Miss A. R., age thirty-two ; admitted Sep- 
tember 23, 1887; parents not living; has been a teacher 
during the past thirteen years. She was a fine scholar — 
standing the first in her class at graduation — and has risen 
to a high position as teacher. During the previous sum- 



534 LECTURES ON MENTAL DISEASES. 

mer vacation she had been in the country, but much en- 
gaged in planning the organization of a department of 
physics, of which she was to have charge the next year. 
Her sisters report that she did not appear quite as well as 
usual when she left the country for the city to resume the 
duties of the school, but little or nothing was thought of 
this. She entered at once upon duty at the opening of the 
school, and five days afterward felt " so nervous " that she 
consulted her physician and did not hear her classes ; that 
same night she became delirious, and remained without 
sleep during seventy-two hours, when she was brought to 
the Retreat, with the report that notwithstanding the ad- 
ministration of three grains of morphine, with doses of 
chloral and bromide, during the previous night she had not 
slept and it required four persons to control her. 

At the time of admission the pulse was ioo per minute, 
quite weak, but there was no rise in the temperature. 
The tongue was covered with a whitish coat and dry. 
She was constantly talking, repeating meaningless, ram- 
bling sentences or words, and addressing persons whom 
she seemed to see passing. The movements of hands 
and feet were constant, and she rolled from side to side, 
and would have gone to the floor if permitted. She was 
given hypodermically one-hundredth of a grain of hyos- 
cine, but no chloral or morphine. The next night she 
slept one and one-half hours, and about the same on the 
third and fourth nights. There was no sleep on the fifth 
night, but from this time forward there were two or more 
hours of sleep every night. After one or two days the 
tongue became brown, the lips dry and cracked, and the 
teeth covered with dark sordes, the bowels were con- 
stipated, the throat filled- with thick, tenacious mucus, 
and she was unable to swallow. On the fifth night 



ACUTE DELIRIUM. 535 

the pulse rose to 140, and the temperature to ioo^°. 
She was no longer able to articulate words, but still 
exhibited great motor activity. On the sixth and seventh 
and eighth days there was less of morbid restlessness, 
and by removing the mucus from the throat she was 
able to swallow a little tea. From the first there had 
been intolerance of all kinds of food, and even a small 
quantity of any liquid was soon vomited. From the tenth 
day after admission the stomach became tolerant of tea and 
milk and there were two or three movements of the bowels 
on some days. The enemata, which had been administered 
from the first, were sometimes expelled. Signs of returning 
consciousness began to appear, and she seemed to compre- 
hend in some measure what was said to her. The pulse 
dropped to 82, and became stronger, and convalescence 
became established. At no time did there appear any 
petechial spots or sudamina, nor did the temperature rise 
above 100^ degrees, nor did there appear any of the 
pemphigus-like eruptions on the limbs, such as appeared 
in Case 2. 

I cannot but regard the effect of the hyoscine in this case 
as most favorable. Insomnia is one of the most marked 
features of this form of disease, and in this case other drugs 
had been faithfully tried without success. This appeared 
to control the marked motor activity in some measure, and 
by this means permitted some sleep during every twenty- 
four hours after the first night, with one exception. The 
strength was conserved by the use of frequent and large 
nutrient enemata, composed of beef tea, milk, and eggs. 
The marked value of this was shown by the fact that as 
late as the fourteenth day after admission, and while she 
was using milk and tea without disturbance of the stomach, 
an omission of the enemata for sixteen hours was attended 



53^ LECTURES ON MENTAL DISEASES. 

with increase in frequency of the pulse and greater weak- 
ness of it. 

On the other hand, in fatal cases, which are far more 
numerous, the stupor becomes more profound, the pa- 
ralysis of the vaso-motor nerves more complete, the blood 
settles under the nails of the fingers and toes, the capillary 
vessels of the dorsal surfaces become congested, render- 
ing them of a dark blue color, the action of the heart 
more feeble, respiration more frequent, until the scene 
finally ends in a condition of profound insensibility and 
coma. 

Example 2. — J. A. T., a female; age, twenty ; single; 
admitted in May, 1887; had worked during some months 
in an envelope factory. Her mother and father both living 
and invalids; both, said to be affected with " nervous " dis- 
orders, and the mother to have been confined to her bed for 
along time. Distant relations on both sides of the family 
have been insane. Patient had had the care of an invalid 
mother for two years prior to entering the factory, and had 
become somewhat invalided, and was at one time hysterical 
and under the care of a physician. Some eight days prior 
to admission, and while at work in the factory, she became 
suddenly excited, and said that some one had given her a 
" love powder," and continued to talk wildly and rush about 
the room where she was, until she was removed to her 
room in a carriage. After her arrival at the house she 
complained of pain in her stomach and had a slight con- 
vulsion ; her excitement increased, and she screamed and 
shouted, at times shed tears, and was continually walking 
about the room into which she was locked, and tried to 
throw herself from the window. This general state of ex- 
citement continued without abatement during some days, 
and she obtained but very little sleep from the medicines 



ACUTE DELIRIUM. 537 

which were administered for the purpose of securing it, 
when she was removed to the Retreat. 

On admission she was talkative and restless, but not 
greatly excited ; would not stand on her feet, but persisted 
in remaining on the floor; had no appetite; tongue was 
covered with a creamy, white coat, and bowels costive. She 
did not apparently sleep, and her mind was much confused, 
so that she could not respond to questions, even if she 
made an effort to do so, which was seldom the case. After 
a day or two she would remain on the bed when placed 
there, and sometimes turn on her face, remaining in that 
position until the attendant placed her on her side or back. 
A whitish mucous secretion formed in the throat and ran 
out of her mouth, which she did not seem to notice ; the 
pulse became weaker, though not rapid ; the extremities 
were often cold, and she became more stupid, and took food 
in fluid form only when it was placed in her mouth. At 
the time of admission there was observed on the anterior 
portion of the chest, abdomen, and legs an eruption of 
pemphigus-like vesicles. As the case progressed these in- 
creased in number, and were located very irregularly upon 
the whole anterior surface of the body and legs. The feet 
and hands also became of a dark purple color, and the blood 
settled under the nails, while on the anterior surface of the 
knee, below the patellae, the integument became swollen, 
inflamed, and very sensitive, though there was a degree of 
anaesthesia in other portions of the body. Food was given 
in fluid form by the stomach and rectum in an abundant 
quantity, but she continued to become weaker and more 
stupid, and, finally, became comatose, in which state she re- 
mained several hours, and died on the thirteenth day after 
admission. 

Morbid Anatomy. — It is thought to be more difficult to 
46 



53$ LECTURES ON MENTAL DISEASES. 

determine, in cases of acute delirium, whether the appear- 
ance of morbid changes is due to the active progress of the 
disease or to the conditions which result from them in the 
process of death and shortly afterward. Hence many of 
the early writers upon this form of disease report little 
morbid anatomical change, and, basing apparently their 
opinion upon the character of the symptoms, regarded the 
disease as one of cerebral anaemia or inanition. All 
modern authors are agreed, however, upon certain changes 
and appearances of the brain and its envelopes, among 
which may be mentioned the following : ist. A large con- 
gestion of the meningeal membrane and a distention of the 
veins and sinuses, with dark venous blood. 2d. The 
capillaries of the surface of the brain and also of the ven- 
tricles are injected. 

3d. In some cases there is found to exist an adhesion of 
the pia mater to eminences of the anterior convolutions 
quite similar in character to what is found in general 
paresis. 

4th. The grey substance is more or less injected, and 
according to Schule presents a peculiar pinkish-red dis- 
coloration. According to Briand, this appearance upon the 
surface is secondary in the order of occurrence, that is, it 
originates in the lower layers of the grey substance, and 
gradually rises as the disease progresses toward the super- 
ficial surface. In only a limited number of cases, and such 
as die during a protracted second stage, are there found 
indications of congestion and engorgement in the white 
substance. The basal ganglia are affected to the same 
extent as the cortex, and are changed in color. This is 
thought by Pauly to be due to a transudation of the color- 
ing matter of the blood through the coats of the capillary 
vessels. Briand has also found, after an examination of 



ACUTE DELIRIUM. 539 

many cases, the existence of a peculiar red color of the 
internal coat of the aorta near the level of its large curva- 
ture, a diminution of the red globules of the blood, and 
collections of leucocytes. In many cases there is found an 
©edematous condition of the convolutions and an increase 
of the cerebro-spinal fluid. (Ball.) Such marked lesions of 
the substance and envelopes of the brain as above men- 
tioned indicate very clearly that the acute delirium is con- 
nected with them in the relation of an effect. 

Diagnosis. — Cases of acute delirium are to be dis- 
tinguished from those of acute mania — 

1st. In the method of advent. The prodromata are 
never well marked, and exist only during a few days, while 
those of mania are recognized for a much longer time, 
unless caused by injury, sunstroke, etc. 

2d. Appetite and digestion are normal or increased in 
mania, while both are absent in acute delirium. 

3d. Mania rarely runs its course in less than two months, 
does not usually develop by a sudden outbreak, and ends 
with a considerable period of convalescence, melancholia, 
or dementia. 

4th. Mania is not usually fatal, and the strength remains 
vigorous throughout the course of the disease ; acute 
delirium is very fatal, and the strength fails almost from 
the first. The mental condition is one of delirium, and 
not attended with imperative concepts, incoherence or 
even disorder of thought, but, on the contrary, all impres- 
sions seem to be exceedingly fleeting and indistinct, unless 
it may be those of danger. When mania is the sequel of 
pneumonia or the puerperal state, these elements of history 
will aid in the diagnosis. Again, some cases of typhoid 
fever, especially those in which the delirium is a very early 
symptom, resemble those of acute delirium, and when 



540 LECTURES ON MENTAL DISEASES. 

cases of the latter disease are not seen until the physical 
symptoms are fully developed, some care in making a 
diagnosis may be necessary. It will, however, be noted 
that the external indications of typhoid upon the chest 
and abdomen are absent, that the temperature does not 
have the characteristics of that of typhoid, and that there 
is an absence of tympanites and tenderness of the intes- 
tinal canal. 

Finally, acute delirium may be distinguished from menin- 
gitis or cerebritis by the absence of the indications of 
a state of acute inflammation. The pulse is not strong 
from the first, and rarely becomes so. The patient does 
not complain of pain, or of sensitiveness to light, or of 
thirst, nor is there an increase of the temperature of the 
external surface of the head. The symptoms indicate 
rather a passive congestion of the capillary vessels of the 
brain. 

Treatment. — The indications for treatment are : — 

First, to procure sleep ; and, second, to sustain the 
patient. The remedies which are of value in producing 
sleep in ordinary cases of insomnia are of little service 
during the early stages of acute delirium. 

If opium is used at all it should be subcutaneously, but 
in my experience both it and chloral have proved utterly 
futile. One of the cases above related took three grains of 
morphine during the night before admission, and apparently 
without any effect — there certainly was no sleep. 

From my experience with the hydrobromate of hyoscine 
I am inclined to recommend this as more likely to allay, 
for short periods, the great motor activity which is so 
constant an attendant, than any other remedy ; and if even 
a few minutes of sleep can be procured it is of the first 
importance. Since the above sentence was written I have 



POST-FEBRILE INSANITY. 54 1 

had occasion to use hyoscine in two cases of acute delirium 
during the early period, and in both with most favorable 
results. The great motor restlessness was much relieved 
and sleep induced. Seclusion in a quiet room, with skill- 
ful and faithful attendants, is a prerequisite to any rational 
treatment. 

When patients can swallow and food can be retained 
upon the stomach, it should be administered often and in 
the form of soups, bouillon, and warm milk. During the 
early stages, and when the stomach rejects food or the 
patient is unable to swallow, it is necessary to sustain by 
nutrient enemata, which should be given as often as once 
in four hours. Wine may be given with the enemata when 
indicated. Warm and prolonged baths and sinapisms are 
indicated, but the difficulties attending their use are so 
great as to almost preclude it. 

The prognosis in acute delirium is extremely grave in all 
cases. It certainly is one of the most formidable of diseases 
we are ever called upon to treat. Recoveries are, however, 
not unheard of, and I am inclined to think, from reports, are 
more common in this country than in Europe. 



POST-FEBRILE INSANITY. 

Trousseau* remarks that delirium is a normal symptom, 
as it were, of typhoid fever and consequently is not to be 
regarded as of serious importance. On the other hand, 
when it appears in some other forms of exanthematous 
disease, for instance, in measles, it is of grave import. This 
fact would seem to point toward one of two conclusions — 
either that the poison that affects the brain in these two 

* " Lectures on Clinical Medicine," Vol. I, page 518. 



542 LECTURES ON MENTAL DISEASES. 

forms of disease is essentially different in character, or else 
that the nervous system is less susceptible to its influence 
in one case than in the other. 

It should be noted that the constitutional susceptibility 
of persons to delirium varies very greatly ; while in some 
any considerable rise of temperature and increase of the 
circulation is attended with a delirious state of the mind, in 
other cases it develops much more slowly and only after 
the system has become overwhelmed by the presence of 
disease. This is especially noticeable in the case of some 
children when affected with fevers of an ephemeral nature, 
and also disorders attended with more serious symptoms. 

The case of a little girl of eleven years of age now occurs 
to me. When taken ill with diphtheria, within six hours 
after the active symptoms of the disease appeared, the pulse 
rose to 130 per minute and the temperature to 103 . She 
suddenly became delirious and continued so for thirty-six 
hours. After this the delirium subsided until a short time 
before death, which occurred on the fifth day. The same 
child had an attack of scarlet fever at five years of age. 
One of the first indications of the disease was a slight con- 
vulsion and afterward an active delirium, which continued 
about twelve hours. The susceptibility to delirium doubt- 
less continues during the early period of adult life in many 
persons. 

We know little or nothing of the remote cause of delirium, 
and, therefore, are unable to say why one person is so 
much more susceptible to its advent than another. But 
the same is true in reference to other and systematized 
forms of insanity. We know definitely very little of the 
nature of their aetiology except what may relate to the 
proximal elements of it. It is, however, reasonable to 
conclude in all cases that the derangement depends very 



POST-FEBRILE INSANITY. 543 

largely upon an unstable constitution of the brain itself. 
Such a condition existing, and its activity would become 
greatly increased and disordered by otherwise inoperative 
causes. Delirium may occur as an independent symptom 
during the existence of other forms of mental disorder. 
I now have a case of folie circulaire of several years' 
duration. This patient nearly a year ago had pneumonia. 
During its progress he had delirium,, which continued for 
several days and disappeared as convalescence advanced. 

The delirium of typhoid fever, which is not usually a 
serious symptom, is the most common of all the nervous 
symptoms which are sometimes present in that form of 
disease, and it is especially important to differentiate it from 
another form of mental disturbance which is sometimes 
present at a later stage or during convalescence, and which 
may indicate an affection of the membranes of the brain or 
in some cases of the grey matter itself. This condition is 
attended with marked impairment of the intellectual facul- 
ties, mental confusion, a semi-stupor at times, and a degree 
of hebetude at all times, a loss of memory, transitory hal- 
lucinations, and generally with symptoms of a depressive 
character. This nervous and mental complication, which 
sometimes attends convalescence from typhoid fever, has 
long been recognized as not an unfrequent one. It may 
be comparatively transient and continue only for a few 
weeks, or it may remain for some months. The period of 
its continuance will depend largely upon the profoundness 
of the effect which has been produced upon the nervous 
system by the experience of a disorder of a zymotic cha- 
racter, and the rapidity with which the poisonous elements 
may be eliminated from the system. In some cases the 
effects remain indefinitely and the system never fully regains 
its former state of healthy action. The mind is less force- 



544 LECTURES ON MENTAL DISEASES. 

ful and initiative ; all ambition for undertaking new enter- 
prises is absent, and there is present a state of comparative 
feebleness, inactivity, and good nature. 

There is still another class of typhoid patients in which 
the intellect becomes deranged from a deterioration and 
impoverishment of the blood. This may arise from an 
insufficient supply of food during the most active period 
of the disease, or from a large loss of blood from hemor- 
rhages from the bowels, or, finally, from a constitutional 
weakness of the assimilative organs, which becomes in- 
creased under the depressive influence of a grave disorder 
and renders them incapable of fully supporting the system. 
In either case the nerve elements of the brain become 
profoundly affected and pass into a state of abnormal 
activity ; they reenergize only in a partial degree, are 
unstable and irregular in action, and remain in a state of 
weakness during a considerable period. The gravity of 
this mental disturbance will depend largely upon the pre- 
vious habits of the individual and his former experience of 
diseases. 

The importance of these three forms of mental disorder 
will be in the inverse order of their mention. The first is 
of comparatively little significance as to after effects upon 
the mind, and its disappearance is one of the indications of 
approaching convalescence. The second is more important, 
may be attended with long-continued effects, and presents 
special indications for care and treatment. The third con- 
stitutes a form of mental disorder by itself. 

/Etiology. — Several writers during the last half century 
have described more or less fully the aetiology and symp- 
toms of post-febrile insanity ; the first of whom, so far as I 
know, was Chomel in 1834. It was formerly supposed that 
its most important aetiological factor was an imperfect 



POST-FEBRILE INSANITY. 545 

elimination of effete material from the system during the 
active course of the disease. Treatment of a very heroic 
character in nearly all forms of acute disease was then 
regarded as very essential, and any neglect of it as likely 
to be followed by unfavorable results in some form or 
other. However important heroic treatment might be 
regarded then, it is certain that a great change in this 
respect has taken place within the last 30 or 40 years. It 
is also true that there has occurred a change more or less 
great in the character of exanthematous disease; malarial 
and typhoid fevers have largely taken the place of typhus 
and pernicious fevers. It is also probable that the human 
system in the present conditions of living would be less 
able to bear the drastic measures of medication then in 
vogue than was the case formerly. Whether these changes 
in the intensity of disease and in methods of treatment 
have any relation other than that of sequence it is not 
necessary for us to inquire at present. It is only impor- 
tant to bear in mind the fact that insanity as a sequel of 
these diseases appears to be of less frequent occurrence at 
the present time than it was formerly. And, if the most 
important aetiological factor is an impoverished condition 
of the nerve cells and medullated fibres of the brain 
arising from an anaemic condition of the system, we may 
fairly conclude that its less frequent occurrence is due in 
part or wholly to the two changes above alluded to. First, 
a less sthenic form of the disease itself, attended with a less 
profound shock to the system and less depression of its 
nervous energy. Second, an abandonment of the heroic 
mode of treatment and the adoption of one attended with a 
larger degree of conservation of systemic energy. 

The less frequent occurrence of post-febrile insanity 
during the recent past in Connecticut is shown by an ex- 



54-6 LECTURES ON MENTAL DISEASES. 

animation of the records of the Retreat and the Hospital at 
Middletown ;" and I have reason to believe that the records 
of other institutions in New England exhibit a similar 
diminution in such cases. In this connection, and as indi- 
cating another aetiological factor of post-febrile insanity, I 
may refer to the change which has occurred in prescribing 
the diet of patients during the continuance of fever. 

The old maxim used to be, " Feed a cold and starve a 
fever." Now all this is changed. I believe that Dr. Graves, 
of Dublin, was the first to call the attention of the profession 
to the importance of feeding fever patients. He was greatly 
in earnest on this subject, and in his lectures used to say to 
his pupils, " If you are at a loss for an epitaph to inscribe 
on my tomb, you may use these words, ' He fed fevers.' " * 

It is not easy to conceive of a procedure in the conduct 
of fevers which would be more likely to induce a condition 
of anaemia and perverted nutrition than that of starvation. 
And this was quite literally the course formerly pursued. 
The fact that the patient did not call for food, or while in 
a state of stupor and delirium refused to use it when offered, 
was thought to be an indication of nature that the system 
did not require it; consequently it was left to feed upon 
itself. How thoroughly erroneous and positively injurious 
such a course was I need not take time to indicate. It 
appears reasonable to conclude that the course now pur- 
sued, of sustaining the system with a variety of easily 
digested food throughout the whole course of the fever 
may be a very important reason why we now have so few 
cases of subsequent mental derangement. 

Symptoms. — The symptoms of post-febrile insanity 



*" Clinical Lectures on the Practice of Medicine," vol. r, p. 119. (This 
statement not found in American edition of Graves' Lectures.) 



POST-FEBRILE INSANITY. 547 

cover a considerably wide range. They may be of an 
excited or depressed type, as the inhibitory centres may or 
may not become involved, with attendant hallucinations, 
delusions, imperative concepts, and morbid impulses. In 
mild cases the disorder consists mainly of an enfeeblement 
of the mental and physical powers. The circulation be- 
comes slow, the extremities cold, the muscular system 
weak, and the secretions comparatively inactive. The mind 
becomes depressed and apathetic, and, in some cases, a 
state of semi-stupor supervenes which may remain during 
several weeks. 

In other cases the brain becomes still further reduced, 
and patients are more or less excitable or excited, talka- 
tive, and restless. A state of mental confusion may arise 
in which imperative concepts usurp the sphere of con- 
sciousness and largely dominate it. And not unfrequently 
they lead on to imperative acts and morbid impulses. 
There is very little sequence of thought ; the mind passes 
from one subject to another with no apparent reason, and 
patients ramble on, using words which have little, if any, 
relation to the supposed subject of conversation*. Halluci- 
nations of all the organs of sense, and also illusions, are 
frequently present. Patients often hear voices and mistake 
strangers for those whom they have formerly known. The 
hallucinations sometimes become so numerous and vivid 
and are so constantly present as to create a state of mental 
confusion or panoramic phantasm. Delusions may be 
either of a transient or a permanent and more systema- 
tized character. They may develop slowly from the pres- 
ence of hallucinations and delirious concepts, or rapidly 
from some trivial exciting cause acting upon a brain in a 
state of debility. Delusions of suspicion and fear are more 



54-8 LECTURES ON MENTAL DISEASES. 

often present, and sometimes lead to assaults upon sup- 
posed enemies. 

If the assumption that the underlying physical condition 
of the symptoms is one of anaemia and perverted nutri- 
tion be correct, we are prepared to anticipate not only a 
considerably wide range of symptoms, but also the fact that 
this form of insanity is likely to develop from the experience 
not alone of exanthematous and exhaustive fevers and 
pneumonias, but from profound injuries and shocks to the 
nervous system and from the protracted effects of surgical 
operations ; in short, from any experience which induces 
the physical state referred to. An examination of a consider- 
able number of cases shows that this is true. Dr. Henry 
M. Hurd, in an interesting article * on this form of insanity, 
has given a summary of 23 cases the histories of which he 
has investigated. Of these 23 cases eleven were the sequence 
of typhoid fever ; in seven of the eleven, delusions of fear and 
apprehension were present ; in one, delusions of grandeur ; 
and, in all the others, marked mental enfeeblement. Two 
were the sequence of pneumonia. Nine of the 23 cases 
were surgical. In these the mental complication appeared 
about the ninth day. In five of these there was depression 
and in four excitement. Four recovered, five died, and 
one did not recover. Eight of the eleven cases following 
typhoid fever recovered, two died, and one did not recover. 
Both cases of pneumonia recovered after a protracted illness. 

In cases occurring after surgical operations the ques- 
tion of the influence which anaesthetics may have had 
occurs. In the majority of surgical cases the insanity 



* Read before the Medical and Chirurgical Faculty of Maryland, April zi 
1892. 



POST-FEBRILE INSANITY. 549 

seems to develop before a condition of anaemia and per- 
verted nutrition has become established, and it becomes 
necessary to look for other causes. These may be found 
in the depressing influence upon the nervous system of very 
sensitive persons which the anticipation of an operation 
produces ; the shock, which is more or less profound accord- 
ing to the nature of the operation, and the subsequent 
uncertainty of a successful issue. The importance of this 
last factor must be considerable in some cases. Indeed, it 
has often been observed that cases not followed by the 
development of insanity do well or otherwise largely as 
the element of expectancy and hope predominates in the 
mind of the subject. In my own experience I have never 
known of a case of systematized insanity which apparently 
resulted from the use of anaesthetics, and after surgical 
operations of a severe nature insanity as a sequence is 
certainly rare. Therefore other aetiological factors must 
exist in the majority of such cases. 

Von Frank Hochwart* reports thirty-one cases of in- 
sanity which have followed eye-operations. These were 
divided into four groups : First, hallucinatory confusional 
insanity ; second, simple confusional insanity in old people ; 
third, psychoses in chronic alcoholism; fourth, cases of 
confusional insanity in very marasmic individuals with 
other intercurrent somatic diseases with fatal termination. 
He concludes that insanity is more frequent after eye- 
operations than after other surgical operations. 

It will be observed that in three of the above four classes 
of patients there existed at least one setiological factor 
beside the operation, viz. : first, old age ; second, alcohol- 



* For a review of Von Frank Hochwart's paper, see American Journal of 
Psychology, vol. iv, No. 2, pp. 331, 332. 



550 LECTURES ON MENTAL DISEASES. 

ism; and third, marasmus. Any one of these, would be 
likely to prove a more important element in the develop- 
ment of the subsequent insanity than the operation itself. 

More than fifty per cent, of the cases which I find upon 
the records of the Retreat were chronic at the time of 
admission. The histories of many of these is imperfect. I 
have, therefore, selected only cases which were reported to 
be acute at the time of admission, i. e. y they were brought 
to the Retreat so soon after the subsidence of the fever that 
there could be no doubt as to their aetiology. These cases 
number 35 — 18 males and 16 females. Heredity was stated 
to exist in 16 of these; no heredity in ten, and no state- 
ment was made on this point in the other eight. In 17 the 
form of fever is not stated, the record being simply fever. 
In seven it was typhoid, in four typhus, in two pneumonia, 
in one scarlet, in one gastric, in one malarial, and in one 
ague and fever. In 15 the form of the subsequent mental 
disorder was melancholia, in 17 mania, and in two de- 
mentia. Eight were excited and at times violent ; five were 
suicidal. Eighteen had delusions mostly of fear and sus- 
picion, three had delusions of poisoning, and one delusions 
of grandeur. Hallucinations, suspicions, semi-stupor, in- 
coherence, mental confusion, and enfeeblement were present 
at times in a large percent, of the cases. Twenty-one, i. e., 
61 per cent, of all the cases, recovered, eight did not re- 
cover, and five died. 

Prognosis. — The prognosis in nearly all forms of recover- 
able insanity depends very much upon the length of time 
it has existed, and this is true of post-febrile insanity. 
There can be no doubt that the large majority of cases 
recover at their own homes and do not find their way to 
asylums ; and the large proportion of those patients who 
do go to institutions have been under home treatment dur- 



POST-FEBRILE INSANITY. 551 

ing months, and, in many cases, more than a year. When 
such treatment has proved unavailing and the prospect of 
a recovery has greatly diminished they seek the care of an 
asylum. More than fifty per cent, of the thirty-five cases 
from the records of the Retreat were not placed under its 
care until several months after the subsidence of the fever, 
and yet there was a recovery in sixty-one per cent. Eight 
of the eleven fever cases in Dr. Hurd's group recovered. 
It may properly be inferred from our reference to the 
aetiology of the disease that the prognosis will also depend 
considerably upon treatment received as to food during 
the active stages of the fever, and upon the period of its 
continuance. On the whole, it may be regarded as one of 
the most curable forms of insanity. 

Treatment. — The treatment of post-febrile insanity 
should embrace all measures which promise a restoration 
of the general physical health. These will include a suffi- 
ciency of easily digested food given five or six times daily, 
bitter tonics, beer, and in some cases strychnine and iron. 
As soon as possible the patient should be removed to the 
open air and kept out-of-doors several hours every day. 
Diversion in the way of games, reading, walking, or riding, 
and some kind of light employment as soon as the patient 
is able to attend to it, will all be of service. 

As the condition of the system is one of debility it is not 
necessary, nor in many cases desirable, that patients should 
be removed from their own homes and the care of friends. 
The change to an institution and to the care of strangers is 
likely to produce a more unfavorable effect than such a pro- 
ceeding usually does in some other conditions of the system. 
The same hesitation should be exercised in taking this step 
as in cases of senile insanity. If the conditions are favor- 
able, treatment at home should first be tried. An early 



552 LECTURES ON MENTAL DISEASES. 

removal to an institution may, however, become necessary, 
as in senile insanity, for the interests of the other members 
of the family. Cases which are attended with very acute 
symptoms or dangerous tendencies should at once be re- 
moved to an institution. It has been suggested that the 
care of patients as to food during the active period of fever 
may exercise a large influence as an aetiological factor. 
The importance, therefore, of securing the frequent adminis- 
tration of food throughout its active course as a prophylactic 
measure will be appreciated. It should be borne in mind 
that the system has generally to pass through the experience 
of a long protracted disease, and hence the importance of 
every measure which will tend to conserve the nervous 
energy. For this purpose food should be given freely from 
the commencement of the fever. The character of the food 
should be adapted to the condition of the stomach. Many 
cases of typhoid fever which are attended with good nursing, 
frequent baths, and a sufficiency of easily digested food 
pass to a successful issue, with little medicine and without 
unfavorable sequences. 



APPENDIX 



47 



Extracts from the Laws of the Different States 

and Territories of the United States which 

relate to the General Care of the Insane. 



The following pages relate more particularly to the duties and responsi- 
bilities of physicians and officers of the law in reference to committing insane 
persons to institutions for care and treatment; their general management 
while under treatment, and their discharge from institutions. 

As the Laws of the States differ very considerably in reference to the form 
of proceeding necessary to be followed in these several respects, it is thought 
desirable that from the great body of Statutes relating to the management of 
the Insane such extracts as relate to the duties of physicians should be compiled 
and made easy for reference. It is believed that the following arrangement 
will prove to be of service, especially to general practitioners. 



ACTS OF ALABAMA, 1886-87. 

Regulating the Admission and Discharge of Patients in the Alabama 
Insane Hospital. 
Section i. — Be it enacted by the General Assembly of Alabama that the 
word " insane " where it occurs in the act incorporating the Alabama Insane 
Hospital, shall be construed to mean any person who, by reason of an unsound 
mind, resulting from disease of brain, is incapable of managing and caring for 
his own estate, without danger to himself or others if permitted to go at large 
or is in such condition of mind or body as to be a fit subject for care and 
treatment in the hospital for the insane ; provided that no person idiot or 
imbecile from birth, or whose mental development was arrested by disease or 
physical injury prior to the age of puberty, or any person who is afflicted 
with simple epilepsy, shall be regarded as insane, unless the manifestation of 
abnormal disability, violence, homicidal or suicidal impulses are such as to 
render his confinement in the hospital a proper protection to prevent him from 
injuring himself or others. 

555 



55^ APPENDIX. 

Sec. 2. — Be it further enacted that authority to discharge patients from the 
Hospital is vested in the Trustees, and may be delegated by them to the 
superintendent, under such regulations as they may see proper to adopt. 
************** 

Sec. 3. — Be it further enacted that the Superintendent of the Hospital has 
authority to furlough for a period not exceeding six months, such of the harmless 
and convalescent patients as in his opinion may be benefited by the change. 
* * * * * Proviso to effect that expenses of furlough be borne by the 
parties. 

Sec. 4. — Be it further enacted that persons confined as insane, shall be 
entitled to the benefit of a writ of habeas corpus. * . * * * * 

REVISED CODE OF ALABAMA, 1886-7. 

Section 1237. — Order of Admission. 

In order of admission, the indigent insane must have piecedence of the rich, 
and recent cases of both classes must have precedence over those of long 
standing. The paying patients from other States may be received into the 
Hospital should vacancies occur unclaimed by natives or residents of Alabama. 

Sec. 1 241. — Investigation of Insanity and Admission to Hospital of 
Indigent Persons. 

When a person in indigent circumstances becomes insane, application can 
be made by his friends, or any other person in his behalf, to the Judge of the 
Probate Court in the county where he resides; and such Judge must without 
delay make application to the Superintendent of the Hospital for his admission. 
************** 
When informed that the applicant can be received, the Judge must call one 
respectable physician and other trustworthy witnesses, and fully investigate the 
facts in the case, and either with or without the verdict of a jury, at his discretion, 
must decide the case as to insanity and indigence; and if the Judge believe 
that satisfactory evidence has been adduced showing the patient to be insane, 
and his estate insufficient to support him and his family (or himself alone if 
he has no family) under the visitation of insanity, he must, upon the Judge's 
certificate, be consigned within thirty days to the hospital, at the expense of 
the county, and be supported there at the expense of the State; and the 
superintendent shall be required to keep the vacancy for a period of thirty 
days after the date of notice that patient can be received. The Judge in all 
such cases shall have the requisite power to compel the attendance of witnesses 
and jurors, and must file the certificate of the physician and other papers 
relating to the case, with a report of the proceedings and decision. 

Sec. 1249. ******* *** 

No patient must be received or discharged without suitable clothing, and if 
it cannot otherwise be obtained the steward must furnish it and charge the 



LEGAL CARE OF THE INSANE. 557 

same to the county from which he was sent. The patient must also be fur- 
nished by the steward, if it is not otherwise to be had, with money sufficient, 
not to exceed $20.00, to pay his expenses until he reaches home ; and the ccst 
of clothing and money advanced must have precedence over other claims, and 
be repaid promptly by the Commissioners of the county from which the patient 
comes, into the county treasury. 



REVISED STATUTES OF ARIZONA, 1887. 

Insane Persons. 

Paragraph 2156, Section i. — The Probate Judge of any county in this 
Territory, upon the application under oath setting forth that a person by reason 
of insanity is dangerous, being at large, shall cause such a person to be brought 
before him for examination, and shall cause to be summoned, to appear at such 
examination, two or more witnesses acquainted with the accused at the time of 
alleged insanity; who shall be examined on oath as to the conversation, man- 
ners, and general conduct of the accused upon which such charge of insanity 
is based ; and shall also cause to appear before him one or more graduates 
of medicine, and known to be reputable practitioners thereof, who shall be pres- 
ent at such examination, and personally examine accused, and shall set forth in 
written statement to be made by one of them : first, his or their judgment as to 
the insanity of the person charged ; second, whether it be dangerous to the 
accused, to the person, or property; third, whether such insanity is in his or 
their opinion likely to prove permanent or only temporary ; and upon such a 
hearing and statement as to the aforesaid, if the proofs shall satisfy the Judge 
before whom such hearing is had, that such party is insane, and that by reason 
of his or her insanity he or she be in danger, if at liberty, of injuring himself 
or herself, or the person or property of others, he shall, by an order entered 
by record in a book kept for that purpose, direct the confinement of such 
person in the Territorial Insane Asylum, who shall be confined therein and not 
discharged until sufficiently restored to reason. 

Paragraph 2157, Sec., 2. — The principal supervisors of each county shall 
cause such person to be conveyed to the Territorial Insane Asylum, and shall 
present for the safe confinement and care of such person, suitable place in such 
asylum, and shall draw their warrants in payment of proper costs and charges 
therefor upon the county treasury ; and the county treasury shall pay such 
warrants out of the general fund as other warrants are paid from such fund ; 
provided, that such insane person shall have no money or property from which 
said cost and charges may be paid, according to the provision of this act. 



5 5§ APPENDIX. 

ACTS OF ARKANSAS, 1889. 

Section I. — Female Attendant to be Provided. 

That all females who have been adjudged insane by proper authorities, shall 
be accompanied from the county seat so adjudged, to the insane asylum, by at 
least one female as an attendant or protector, and the said female attendant 
shall receive the same compensation as is now paid to male attendants for the 
same service. 

ACT II. 

Section i. — Privileges of Inmates in Correspondence. 

That from and after the passage of this act each and every inmate of each 
and every insane asylum, either public or private, in the State of Arkansas, 
shall be allowed to choose one individual from the outside world to whom he 
or she may write when and whatever he or she desires, and over these letters 
to this individual there shall be no censorship exercised or allowed by any of 
the asylum officials or employees; but their post-office rights, so far as this 
one individual is concerned, shall be as free and unrestrained as are those of 
any other resident or citizen of the United States, and shall be under the pro- 
tection of the same postal laws; and each and every inmate shall have the 
right to make a choice of the individual party every three months if he or she 
so desire to do ; and it is here made the duty of the superintendent to furnish 
each and every inmate of every insane asylum, either public or private, in the 
State of Arkansas, with suitable material for writing, enclosing, sealing, stamp- 
ing, and mailing letters, sufficient at least for writing of one letter per week, 
provided they request the same, unless they are otherwise furnished by the 
writers thereof, accompanied by an attendant when necessary, into a post- 
office provided by Congress at the insane asylum, and kept in some place of 
easy access to all patients. The attendant is required in all cases to see that 
this letter is directed to the patient's correspondent, and if it is not so directed 
it must be held subject to the superintendent's disposal, and the contents of 
these boxes must be collected once every week by an authorized person from 
the post-office department, and by him placed in the hands of the United States 
mail for delivery. 

Sec. 2. — Duties of Superintendent. 

That it is hereby made the duty of the superintendent to keep registered and 
posted, in some public place at the insane asylum, a true copy of the names of 
every individual chosen, and by' whom chosen, and it is hereby made the duty 
of the superintendent to inform each individual of the name of the party 
choosing him or her, and he is to request him or her to write his or her own 
name on the outside of the envelope of every letter he or she writes to this 
individual ; and all these letters bearing the individual writer's name on the 



LEGAL CARE OF THE INSANE. 559 

outside, he is required to deliver, without opening or reading the same, or 
allowing it to be opened or read, unless there is reason for believing the letter 
contains some foreign substance which might be used for medication, in which 
case the letter shall be required to be opened in the presence of a competent 
witness, and this substance shall be delivered as directed. 

Sec. 3. — Violation of the Act by Persons Connected with Asyhims a 
Misdemeanor. 

That any person refusing or neglecting to comply with, or wilfully and 
knowingly violating any of these provisions of this act, shall be guilty of a 
misdemeanor, and upon conviction thereof shall be punished as the civic code 
of the State of Arkansas describes for misdemeanor, and by ineligibility to any 
office in the asylum afterward. 

Sec. 4. — Copy of this Act to be Posted in Wards of the Asylum. 

That a printed copy of this act shall be kept posted in every ward in every 
asylum, both public and private, in the State of Arkansas. 

DIGEST OF THE STATUTES OF ARKANSAS, 1884. 

Section 3769. — When any sheriff, coroner, or constable shall discover any 
person to be of unsound mind, or incapable of managing his own affairs, the 
court shall appoint a guardian of the person and of the estate of such insane 
person. 

Sec. 3815. — Fact of insanity inquired into ; how. 

If any person shall allege in writing, ratified by oath, that any person who 
has been of unsound mind, or addicted to habitual drunkenness, has been 
restored to his right mind or to correct, sober habits, the court in which the 
proceedings were had shall cause the facts to be inquired into in such manner 
as it may direct. 

Sec. 381 1. — Lunatic previously mad ^ may be confined. 

If any person who has been previously mad, or so far disordered in his mind 
as to endanger his own person, or the person or property of others, shall again 
become insane, it shall be the duty of his guardian or person under whose care 
he may be, and who is bound to provide for his support, to confine him in some 
suitable place until the next term of the Probate Court for his county, which 
shall make such order for the restraint, support, and safe- keeping of such person 
as the circumstances of the case shall require. 

Sec. 3812. — Judge or Justice may order confinement. 

If any such person of unsound mind, as in the last section specified, shall 
not be confined by those having charge of him, or if there be no person having 
such charge, any judge of a court of record, or any two justices may employ 
any person to confine him in some suitable place until the court shall make 
further order thereon, as in the preceding section specified. 



560 APPENDIX. 

Sec. 3814. — Insane persons found at large. 

Insane persons found at large, and not in the care of some discreet person, 
shall be arrested by any peace officer and taken before a magistrate of the 
county, city, or town in which the arrest is made. 



CODES AND STATUTES OF CALIFORNIA, 1886. 

Examination and Committal of Insane Persons. 

Section 2210. — Examined before %vhom. 

Whenever it appears by affidavit to the satisfaction of the magistrate of the 
county, that any person within the county is so far disordered in his mind as 
to endanger health, person, or property, he must issue and deliver to some 
officer, for service, a warrant, directing that such person be arrested and taken 
before any Judge of court of record within the county, for examination. 

Sec. 221 1. — Two Witnesses. 

When the person is taken before the Judge, he must issue subpoenas to two 
or more witnesses best acquainted with such insane person, to appear and 
testify before him at such examination. 

Sec. 2212. — Two Physicians. 

The Judge will also issue subpoenas for at least two graduates of medicine to 
appear and attend such examination. 

Sec. 2214. — Duty of Physician. 

The physician must hear such testimony, and must make a personal exami- 
nation of the alleged insane person. 

Sec. 2215. — Certificate of Physicians. 

The physicians, after hearing the testimony and making examination, must, 
if they believe such person to be dangerously insane, make a certificate show- 
ing as near as possible — 

First: That such person is so far disordered in his mind as to endanger 
health, person, or property. 

Second : The premonitory symptoms, apparent cause, the class of insanity, 
the duration and condition of disease. 

Third : The nativity, age, residence, occupation, and previous habits of the 
person. 

Fourth : The place from whence the person came, and the length of his 
residence in this State. 

Sec. 2217. — Duty of the Judge and Clerk on Commitment of Insane. 

The Judge after such examination and certificate made, if he believes the 
person so far disordered in his mind as to endanger health, person, or property 
must make an order that he be confined in the insane asylum. A copy of such 
order shall be filed with a record by the clerk of the county. The clerk shall 



LEGAL CARE OF THE INSANE. 561 

also keep in convenient form an index book, showing name, age, and sex of 
person so ordered to be confined in the insane asylum, with the date of the 
order and the name of the insane asylum in which the person is ordered to be 
confined. No fees shall be charged by the clerk for performing any duties 
provided for by this section. 

Sec. 2222. — Fees of Physicians. 

The physicians attending such examination of an insane person, are allowed 
five dollars, which are to be paid by the Treasurer of the county where the 
examination was had, on the order of the supervisors. 



CODE OF COLORADO, 1883. 

2281 — SECTION 28: (2) — Arrest of various lunatics — Inquest — Verdict — 
Commitment — Custody. 

Whenever any reputable person shall file with the county court a complaint 
duly verified, alleging that any person is so insane or distracted in mind as to 
endanger his own person or property, or the person or property of any other or 
others, if allowed to go at large, the county court or Judge thereof shall forth- 
with issue an order in the name of the people direct to any sheriff or constable 
of the county for the apprehension of such alleged insane person, which order 
may be executed by any sheriff or constable of said county, or by any person 
especially appointed by said court to execute the same; provided ', that when 
any sheriff or constable shall find within his county any such insane person 
at large, it shall be his duty to apprehend such insane person without an order 
of the court. And when any alleged insane person shall be arrested by, or 
without an order of the court, he or she shall be taken forthwith before the 
county court, or Judge thereof, and if the alleged insane person so elect, an 
inquest as provided for in Section I shall be held without delay; and until 
the determination of such inquest, such alleged insane person shall be confined 
in the county jail or other convenient place. If upon such inquest it shall be 
found in the verdict of the jury that such alleged insane person is so insane or 
distracted in mind as to endanger his or her own personal property, or the per- 
son or property of any other or others, if allowed to go at large, it shall be the 
duty of the court to commit such insane person to the county jail or other 
convenient place, to be there confined until discharged on inquest or otherwise 
disposed of according to law. #*###*•*•* 

2237 — Sec. 34. — Definition of the term " Lunatic." 

The term lunatic, as used in this chapter, shall be construed to include idiots 
insane and distracted persons, and every person who, by reason of intemperance 
or any disorder, or unsoundness of mind, shall be incapable of managing and 
caring for' his own estate. 
48 



562 APPENDIX. 

Sec. 2241. — Snperintende7it and Commissioners to report annually. 

The superintendent of the Board of Commissioners shall make a report to 
the Governor on or before the 1st day of December in each and every year, 
showing the condition of the asylum financially, number, age, sex, occupation, 
and residence, treatment and state of reform of persons admitted from the date 
of opening of the asylum or from the date of the last report, together with 
such other facts as their experience and observation may approve and may 
deem in the interest of the public ; the Governor shall cause such reports to be 
published, and he shall present them to the next General Assembly. * * 



ACTS OF CONNECTICUT, 1889. 

Chapter clxii, Section i. — In this act, the words and expressions fol- 
lowing shall have the several meanings hereby assigned to them, unless there is 
something in the subject or context repugnant to such construction, that is to say: 
"Asylum " means any public or private hospital, retreat, institution, house, or 
place, in which any insane person is received or detained as a patient for com- 
pensation ; but shall not include any State prison, county jail, or poorhouse, 
nor any public reformatory or penal institution of this State. " Insane person " 
means and shall include every idiot, non-compos, lunatic, insane, and distracted 
person. " Patient " means any person detained and taken care of as an insane 
person. The words "keeper of an asylum " mean any person, body of persons, 
or corporation, who have the immediate superintendence, charge, management, 
and control of an asylum and the patients therein. Words importing the mas- 
culine gender may be applied to females. 

Sec. 2. — Any Judge of a Probate Court, within his probate district, shall have 
power to commit any insane person residing in said district to an asylum in 
this State, in the manner hereinafter provided. 

Sec. 3. — Except when otherwise specially provided by law, no person shall 
be committed or admitted to an asylum without an order signed by a Judge of 
Probate, as hereinafter provided. 

Sec. 4. — Whenever any person in this State shall be insane, or shall be 
supposed to be insane, any person may make complaint in writing to any Judge 
of Probate, within whose district the person complained of shall reside, 
alleging that such person is insane and is a fit subject to be confined in an 
asylum, and when any insane person, who ought to be confined, shall go at 
large in any town, any person may, and the Selectmen thereof shall, make a like 
complaint to the Judge of Probate within whose district such town is included. 
After receiving said complaint, the Judge to whom it is made shall forthwith 
appoint a time, not later than ten days after receipt of said complaint, and a 
place within said district, for a hearing upon said complaint, 2nd shall 



LEGAL CARE OF THE INSANE. 563 

cause reasonable notice thereof to be given to said complainant, to the person 
complained of, and to such relative or relatives of said person, or to any person 
interested in said person, as said Judge shall deem proper, and may adjourn 
said hearing from time to time for cause. Said Judge may issue a warrant for 
the apprehension and bringing before him of said person complained of, and 
shall see and examine said person, if in his judgment the condition or conduct 
of such person renders it necessary and proper so to do, or state in his final 
order why it was not deemed necessary or advisable so to do. 

Sec. 5. — In addition to such oral testimony as may be given before such 
Judge, at said hearing, there shall be filed with such Judge a certificate signed 
by two physicians, each of whom is a graduate of some legally organized 
medical institution, and has practiced three years in this State, and neither of 
whom is connected with any asylum nor related to the person complained of 
by blood or marriage. Each must have personally examined said person 
alleged to be insane, within five days of signing said certificate, and each 
shall certify that, in his opinion, said person is insane and a proper subject for 
treatment in an asylum ; and a copy of said certificate, attested by said Judge, 
shall be attached to the final order of said Judge and delivered with said order 
to the keeper of the asylum to which said insane person shall be committed. 

Sec. 6. — If, on said hearing, the Judge shall find that the said person is 
insane, and a fit subject for treatment in an asylum, or that he ought to be 
confined, he shall make an order in writing, stating that he so finds, and 
commanding some proper officer, or any fit person, to convey said insane person 
to the asylum named in said order, unless some person shall undertake, before 
said Judge, and shall give bond to the State conditioned to confine such person 
in some suitable place of detention, not an asylum, in such manner as said 
Judge shall order. ********** 

Sec. 16. — All insane persons confined in any asylum in this State shall be 
entitled to the benefits of the writ of habeas corpus, and the question of insanity 
shall be determined by the court or Judge issuing such writ, and if the court 
or Judge before whom such case is brought shall decide that the person is 
insane, such decision shall be no bar to the issuing of said writ a second time, 
if it shall be claimed that said person has been restored to reason. Said writ 
may be applied for by said insane person, or on his behalf by any relative, or 
friend, or person interested in his welfare. 

Sec. 17. — The provisions of this act shall not extend to, nor affect in any way 
the cases of persons convicted of or charged with crime, as provided for in the 
following sections of the general statutes, to wit: Sections 1600, 1601, 1602, 
1603, 3385, 3386, 3615, 3617, 3618, 3619, 3620, and 3621 ; nor shall they be 
construed as repealing sections 487, 3683, and 3684 of said general statutes. 



564 APPENDIX. 

Sec. 18. — The keeper of any asylum in this State may receive and detain 
therein, as a patient, any person who is desirous of submitting himself to 
treatment, and makes written application therefor, but whose mental condi- 
tion is not such as to render it legal to grant an order of commitment as an 
insane person in his case, under the provisions of this act. No such patient 
shall be detained for more than three days after having given notice in writing 
of his intention or desire to leave said asylum. 

Sec. 19. — An attorney at law regularly retained by, or on behalf of, any 
patient in an asylum, or any medical practitioner designated by such patient, 
or by any member of his family, or by some relative or friend of such patient, 
shall be admitted to visit such patient at all reasonable hours, if in the opinion 
of the keeper of said asylum such visit would not be injurious to said patient, 
or if a Judge of the Superior Court first orders in writing that such visit be 
allowed. 

Sec. 20. — All persons detained as insane shall at all times be furnished with 
materials for communicating with any suitable person without the asylum, and 
such communications shall be stamped and mailed daily. Should the patient 
desire it, all rational communications shall be written at his dictation and duly 
mailed to any relative or person named by the patient, 

Sec. 22. — All asylums in this State shall be subject to the inspection and 
visitation of the State Board of Charities, and shall be so visited and inspected 
at least once in six months in each year. 

Sec. 23. — Every person who wilfully conspires with any other person un- 
lawfully to commit to an asylum any person who is not insane, and any person 
who shall wilfully and falsely certify to the insanity of any person in any 
certificate made and filed as provided for in this act, and any person who shall 
wilfully and falsely report to any court or Judge that any person is insane, 
shall be punished by a fine not exceeding one thousand dollars, or by im- 
prisonment in the State prison not exceeding five years, or both. 

Sec. 24. — Every keeper of an asylum who shall wilfully violate any of the 
provisions of sections three, eighteen, nineteen, and twenty of this act shall 
be deemed guilty of a misdemeanor, and may be punished by a fine not 
exceeding two hundred dollars, or by imprisonment in a common jail not 
exceeding one year, or both, at the discretion of the court. 

Sec. 25. — All acts or parts of acts inconsistent herewith are hereby 
repealed. 

LAWS OF DAKOTA TERRITORY, 1887. 

Section 2179. — Appointment of Commissioners of Insanity. 

In each organized county of this Territory there shall be a board of com- 
missioners consisting of three persons, to be styled Commissioners of Insanity, 
two of whom shall consiitute a quorum. * * * * * * 



LEGAL CARE OF THE INSANE. 565 

Sec. 2182. — Duties of the Commissioners and their Power. 

The said commissioners shall have cognizance of all applications for admis- 
sion to the hospital, or for the safe keeping otherwise of insane persons within 
their respective counties, except in cases otherwise specially provided for. For 
the purpose of discharging the duties required of them, they shall have the 
power to issue subpoenas and compel obedience thereto, to demonstrate this 
and any act of the court necessary and proper in the premises. 

Sec. 2183. — Application for Admission to the Hospital. 

Application for admission to the hospital must be made in writing, in the 
nature of an information, verified by affidavit. Such information must allege 
that the person on whose behalf application is made is believed by the inform- 
ant to be insane, and a fit subject for custody and treatment in the hospital ; if 
such person is found in the county and has a legal settlement therein, if such is 
known to be the fact ; and if such settlement is not in the county, where it is, 
if known, or where it is believed to be if the informant is advised on the 
subject. 

Sec. 2184. — Investigation by Commissioners as to the Alleged Insanity — 
Physicians Certificate. 

On the filing of the information as above provided, the commissioners shall 
at once take steps to investigate the grounds of the information. For this 
purpose they may require that the person for whom such admission is sought 
be brought before them, and that the examination be had in his or her pres- 
ence, and they may issue their warrant therefor and provide for the suitable 
custody of such person until their investigation shall be concluded. * * * 
Any citizen of the county, or any friend of the person alleged to be insane, 
may appear and resist the application, and the parties may appear by counsel if 
they elect. The commissioners, whether they decide to dispense with the pres- 
ence before them of such person or not, shall appoint some regular practicing 
physician of the county to visit or see such person, and make personal examina- 
tion touching the truth of the allegations in the information touching the actual 
condition of such person, and forthwith report to them thereon. Such physician 
may or may not be of their own number, and the physician so acting shall 
certify, under his hand, that he has in pursuance of his appointment, made 
careful personal examination as required, and after such examination he found 
the person in question insane, if such be the fact ; and if otherwise, not insane ; 
and in connection with this examination the said physician shall endeavor to 
obtain from the relatives of the pen-on in question, or through other friends who 
know the facts, correct answers as far as may be to the interrogatories herein- 
after required to be propounded in such cases, and such interrogations and 
answers shall be attached to this certificate. 



566 APPENDIX. 

Sec. 2185. — How Patients Should be sent to the Hospital. 

On the return of the physician's certificate, the commissioners shall, as soon 
as practicable, conclude their investigations, and having done so they shall find 
whether the person alleged to be insane, is insane ; whether, if insane, a fit 
subject for treatment and custody in the hospital ; whether the alleged settle- 
ment of such person is in their county, if not in their county where it is, if 
ascertained. If they find such person is not insane, they shall order his or her 
discharge, if in custody. If they find such person insane and a fit subject for 
treatment and custody in the hospital, they shall forthwith issue their warrant 
and a duplicate thereof, stating such a finding, with the settlement of the 
person, if found, and if not found, their information, if any, in regard thereto, 
authorizing the superintendent of the hospital to receive and keep such person 
therein. Such warrant and duplicate, with the finding and certificate of the 
physician, shall be delivered to the sheriff of the county, who shall execute 
the same by conveying such person to the hospital and delivering him or her, 
with the duplicate of the physician's certificate and finding, to the superintend- 
ent thereof. The superintendent, over his official signature, shall acknowledge 
such delivery on the original warrant, which the sheriff shall return to the 
clerk of the commissioners, with his cost and expenses endorsed thereon. 

Sec. 2190. — Penalty for Cruelty to the Insane. 

Any person having care of any insane person and restraining such person, 
either with or without authority, who shall treat such person with wanton 
severity or harshness, or shall in any way abuse such person, shall be guilty of 
a misdemeanor, besides being liable to an action for damages. 

Sec. 2199. — Postal Privileges of Inmates. 

Henceforth each and every inmate of each and every insane asylum, both 
public and private, in the Territory of Dakota, shall be allowed to choose one 
individual from the outside world, to whom he may write, when or whatever 
he desires, and over these letters to this individual there shall be no censor- 
ship exercised or allowed by any asylum official or employees ; but their post- 
office rights, so far as this one individual is concerned, shall be as free and 
unrestricted as are those of any other resident and citizen of the Territory of 
Dakota, and shall be under the protection of the same postal laws ; and each 
and every inmate shall have the right to make a new choice of this individual 
party every three months if he so desires to do. And it is hereby made the 
duty of the superintendent to furnish each and every inmate of the insane 
asylum in this Territory, either public or private, with suitable material for 
writing, enclosing, sealing, stamping, and mailing letters, sufficient at least for 
the writing of one letter a week, providing they request the same, unless they 



LEGAL CARE OF THE INSANE. 567 

are otherwise furnished with such material ; and all such letters shall be 
dropped by the writers thereof, accompanied by the attendant when necessary, 
into a post-office box provided at the insane asylum and kept in some place 
easy of access to all patients. The attendant is required in all cases to see that 
this letter is directed to the patient's correspondent, and if it is not so directed 
it must be held to the disposal of the superintendent ; and the contents of this 
box shall be collected once every week by an authorized person of the Post- 
office Department, and by him placed in the hands of the United States mail 
for delivery. 

LAWS OF DELAWARE, 1887. 

Title 60, Chapter 92. Section i. — Proceedings in the Case of Indigent 
Lunatics. 

Be it enacted (etc.) that whenever the relatives or friends of an indigent lu- 
natic or insane person, a citizen of this State, shall apply to the Chancellor of 
this State, either personally or by .petition, together with the certificate of two 
practicing physicians of the county wherein such lunatic or insane person shall 
reside, one of whom shall be the regular physician of the Almshouse of said 
county, setting forth the facts of said lunacy or insanity, the cause or causes, if 
known, and the necessity in their opinion of a better and more efficient mode 
of medical treatment in such case than can be afforded in the Almshouse 
wherein such lunatic or insane person may reside, the Chancellor shall, if satis- 
fied with the proofs offered of such lunacy or insanity, refer such applications 
to the Trustees of the Poor of said county for information as to indigency of 
said person for whom application is made, or any other matter; whereupon, if 
said reports be satisfactory, the Chancellor shall recommend to the Governor 
that such indigent lunatic or insane person be removed to the Insane Depart- 
ment of the New Castle County Almshouse ; provided, that not more than ten 
indigent lunatic or insane persons from each of the counties of Kent and Sus- 
sex shall be in said asylum at the same time; and provided further, that this 
shall not prevent the Trustees of the Poor of either county of Sussex or Kent 
from placing any indigent lunatic or insane person, that may be placed in their 
keeping, in the said Insane Department of the New Castle County Alms- 
house for whom no application may be made, and who, in their opinion, may 
require special treatment. 

Section 3. — When Indigent Lunatics may be Rettirned. 

That whenever the principal physician of the Insane Department of the 
New Castle County Almshouse shall represent to the Trustees of the Poor of 
the county from which said indigent lunatic or insane person may have been 
entered, that any such person has been cured by the treatment prescribed, 
or they are so far benefited and improved in condition as to render his or 



568 APPENDIX. 

her further residence in said Insane Department unnecessary; or that the said 
person is, after full and sufficient opportunity, incurable; then he or she shall, 
upon the written request of said Insane Department, if cured or relieved as 
aforesaid, be discharged from said institution; or if incurable as aforesaid, be 
returned to the Almshouse for cure and confinement. 



LAWS OF DELAWARE, 1889. 

Chapter 553, Section 9. — In all cases of application for the commitment of 
an insane person to the hospital, the evidence and certificate of at least two 
respectable physicians, based upon due inquiry and personal examination of 
the person to whom insanity is imputed, shall be required, to establish the fact 
of insanity, and a certified copy of the physician's certificate shall accompany 
the person to be committed, together with the written order of the Trustees or 
Chancellor, as provided in Section 6 of this act. 



DIGEST, LAWS OF FLORIDA, 1881. 

Chapter 147. — Lunatics. Section 3. — Duty of the Circuit Judge. 

Whenever it shall be suggested, by petition or otherwise, to any Judge of the 
Circuit Court of this State, that there is any lunatic or insane person within the 
limits of the judicial circuit of said Judge incapable of managing his or her 
own affairs or of taking care of himself or herself, it shall be the duty of said 
Judge to issue a writ to the Sheriff of the county wherein such lunatic or insane 
person is*alleged to be, directing him to bring such person before him for the 
purpose of inquiring into the alleged lunacy or insanity. 

Sec. 4. — If it is found upon investigation that such person is a lunatic, or 
insane, the Judge shall pass such order or decree as is usually necessary in 
such cases. 

Sec. 6. — Order for Lunatic to be taken to the Asylum. Order for Private 
care of Lunatic. 

If it shall appear that said lunatic or insane person is destitute, then the 
Judge shall draw an order that the Sheriff shall transport such lunatic or insane 
person to the Asylum for the Indigent Lunatics of the State of Florida, and there 
deliver the lunatic or insane person to the officer having charge of same, for 
the purpose of his care, custody, and treatment; provided, however, that the 
Judge may, in his discretion, direct the said lunatic or insane person to be de- 
livered to any other person for his care, custody, and maintenance, in which 
event the said insane person shall be so delivered, and it shall be the duty of 
the person to whom such delivery is made, to provide for his care, custody, and 
maintenance. *-*-**#*-**-£* 



LEGAL CARE OF THE INSANE. 569 

Sec. 12. — Care of Lunatics for Pay. 

It shall be lawful for the physician in charge of the Asylum for Indigent 
Lunatics of the State of Florida, when directed by the Board of Commissioners 
of State Institutions, to receive into said asylum any lunatic, idiot, or insane 
person, whose friends, parents, or guardians are able and willing to pay for the 
care and custody and maintenance of said lunatic, idiot, or insane person. 

Sec. 13. — Attention, etc. 

Such lunatic, idiot, or insane person shall receive all care, food, clothing, and 
medical attention, as he or she may demand and require, from the physician 
and other employees of the asylum. 

Sec. 17. — Powers. 

The physician of the asylum shall have sole supervision of and immediate 
superintendence of the Asylum for Indigent Lunatics of the State, subject to the 
direction of the Board of Commissioners of State Institutions. 

Sec. 19. — Physician. 

The physician of the State Prison shall also be the physician for such asylum, 
and shall exercise such powers in the matter of care of the inmates of such 
asylum, as may be prescribed by said Board of Commissioners. 

ACTS OF FLORIDA, 1887. 

Chapter 3706. Section i. — Physicians of Asylum to Keep Record of 

Patients, etc. 
That it shall be the duty of the physician in charge of the Insane Asylum of 
this State to thoroughly investigate the history of patients, and upon careful 
diagnosis of same make a record thereof in a book of sufficient magnitude, 
which book shall be termed the "Physician's Bcok of Record;" and such 
record shall contain the name of each person who may thus come under his 
treatment, the name of the disease to be treated, and the date of beginning 
treatment, and each day's prescriptions while under treatment; which record 
shall be open for future reference by his successor, the cabinet officers, legis- 
lative committees, and all others interested. 

ACTS OF 1883. 
Chapter 3444. Section i. — Fee and Mileage. 

That hereafter any practicing physician who shall be called in by the Circuit 
Judge to testify on an investigation as to lunacy or insanity of an indigent 
person who shall be alleged to be a lunatic or insane, ^hall be paid the sum 
of five dollars, and ten cents per mile, by the State, out of appropriations for the 
maintenance of indigent lunatics and insane persons; the same shall be audited 
by the Comptroller on the approval of the Circuit Judge, and paid by the 
Treasurer on the Comptroller's warrant. 



570 APPENDIX. 

CODE OF STATE OF GEORGIA, 1882. 

Sec. 331 (5). — The State Asylum is intended for the care of lunatics, idiots, 
epileptics, or demented inebriates. Inmates are divided into four classes : (1) 
Pay or pauper patients, residents of the State. (2) Pay patients, who are non- 
residents. (3) Insane Penitentiary convicts. (4) Insane negroes, in certain 
cases. Citizens of Georgia have a preference over non-residents. 

Resident pay patients are admitted upon authentic evidence of lunacy ac- 
cording to law, or by a certificate of three respectable physicians and two 
respectable citizens. * * * ******* 

LAWS OF 1889. 

Providi?ig for the Appointment of Guardian or Commitment to 
Lmiatic Asylum. 

Section i. — To have Guardian Appointed or Subject Committed to Lunatic 
Asylum. 

Upon the petition of a person on oath, setting forth that another is liable 
to have a guardian appointed under the provision of this act (or is subject to 
be committed to the lunatic asylum of this State), the Ordinary, upon the proof, 
if ten days' notice of such application has been given to the three nearest adult 
relatives of such person, or if there is no such relative within this State, shall 
issue a commission direct to any eighteen discreet and proper persons, one of 
whom shall be a physician, requiring any twelve of them, including the physi- 
cian, to examine by inspection the person for whom guardianship (or commit- 
ment to asylum) is sought, and to hear and examine witnesses on oath, to 
make return of such examination and inquiry to said Ordinary, specifying in 
such return under which such classes they found said person to come ; such 
commission shall be sworn by any of the officers of this State authorized by 
the laws of this State to administer an oath, " well" and truly to execute said 
commission, to the best of their skill and "ability," which oath shall be re- 
turned with their verdict. 



STATUTES OF IDAHO, 1887. 

Section 750. — The Idaho Insane Asylum, located at Blackfoot, is under 
the management and control of a Board of Directors, consisting of three per- 
sons ************ 

Sec. 756. — The Medical Superintendent must be a graduate of medicine, 
and must have practiced in his profession five years after date of his diploma. 
Sec. 757. — Must reside at and give his entire Time to the Asylum. 
He must reside at the asylum and give his entire time and attention to pro- 



LEGAL CARE OF THE INSANE. 57 1 

mote the best interests of the patients. His duties not specified in this 
chapter must be prescribed by the Board of Directors' by-laws. 

Sec. 758. — General Powers. 

He is the chief executive officer of the asylum, with powers and duties as 
follows : — 

To control the patients, prescribe the treatment, and prescribe and enforce 
the sundry regulations of the asylum. 

Sec. 764. — Discharge. 

Any person received in the asylum must, upon recovery, be discharged there- 
from. 

Sec. 767. — Not Eligible for Admission. 

No person laboring under any contagious or infectious disease must be ad- 
mitted into the asylum as a patient. 

Sec. 769. — Examination before whom. 

When it appears by affidavit, to the satisfaction of a Magistrate of a county, 
that any person within the county is so far disordered as to endanger health, 
person, or property, he must issue and deliver to some peace officer, for service, 
a warrant directing that such person be arrested and taken before any Judge of 
a court of record within the county, for examination. 

Sec. 771. — One Physician. 

The Judge may also issue subpoenas for at least one graduate of medicine to 
appear and attend such examination. 

Sec. 773. — Duty of Physician. 

The physician must hear such testimony and must make a personal examina- 
tion of the alleged insane person. 

Sec. 774. — Certificate of Physician. 

The physician after hearing the testimony and making the examination, 
must, if he believes the person to be dangerously insane, make a certificate in 
his own handwriting, showing as near as possible — 

(r) That such person is so far disordered in his mind as to endanger 
health, person, and property. 

(2) The premonitory symptoms, apparent cause, or class of insanity, and the 
condition of the disease. 

(3) The nativity, age, residence, occupation, and previous habits of the 
person. 

(4) The place from whence the person came and the length of his residence 
in this Territory. 

S EC . 776.— Order of th e Judge. 

The Judge, after such examination and certificate made, if he believes the 
person so far disordered in his mind as to endanger health, person, and property, 
must make an order that he shall be confined in the Insane Asylum. 



57-2 APPENDIX. 

Sec. 778. — Money found on Insane Persons must be delivered to the Asylum. 

Any money found on the person of an insare person at the time of the arrest 
must be certified to by the Judge, and sent with such person to the asylum, 
there to be delivered to the Medical Superintendent, who must deliver the same 
to the Territorial Treasurer. If the sum exceed one hundred dollars, the ex- 
cess must be applied to the payment of expenses of such person while in the 
asylum, and delivered to the person when discharged, or applied to the pay- 
ment of funeral expenses if the person dies at the asylum. 

Sec. 781. — Fee of Physician. 

The physician attending each examination of an insane person is allowed 
five dollars, to be paid by the County Treasurer of the county where the exam- 
ination was had, on the order of the Board of County Commissioners. 



STATUTES OF ILLINOIS, 1881. 

Chapter 85, Page 950. — Lunatics. Section i. Petition. 

That when a person is supposed to be insane or distracted, any near relative, 
or in case there be none, any respectable person residing in the county, may 
petition the Judge of the county court for proceedings to inquire into the 
alleged insanity or distraction. For the hearing of such applications and 
proceedings thereof the county court shall be considered as always open. 

Sec. 2. — Writ-Service. 

Upon the filing of such petition the Judge shall order the clerk of the court 
to issue a writ, directed to the Sheriff or any constable, or the perscn having 
custody of the alleged insane or distracted person, unless he shall be brought 
before the court without such writ, requiring the alleged insane or distracted 
person to be brought before him at a time and place to be appointed for the 
hearing of the matter. It shall be the duty of the officer or person to whom 
the writ is directed to execute and return the same and bring the alleged 
insane person before the court as directed in the writ. 

Sec. 4. — Jury Trial. 

At the time fixed for the trial, a jury of six persons, one of whom shall be 
a physician, shall be impanneled to try the case. The case shall be tried in 
the presence of the person alleged to be insane, who shall have the right to be 
assisted by counsel, and may challenge the jurors as in civil cases; the court 
may for good cause continue the case from time to time. 

Sec. 5.— Verdict. 

After hearing the evidence the jury shall render their verdict in writing, 
signed by them, which shall embody the substantial views shown by the 
evidence. 



LEGAL CARE OF THE INSANE. 573 

Sec. 6. — Verdict Recorded ; Order of Committal ; Application. 

Upon the return of the verdict the same shall be recorded at large by the 
Clerk, and if it appears that the person is insane and is a fit person to be sent 
to the State Hospital for the Insane, the court shall enter an order that the 
insane person be committed to the State Hospital for the Insane ; and there- 
upon it shall be the duty of the Clerk of the Court to make application to the 
Superintendent of some of the State Hospitals for the Insane for the admission 
of such person. 

Sec. 8. — Warrajit to Commit. 

Upon receiving notice at what time the patient will be received, the clerk 
shall, in due season for the conveyance of the person to the hospital by the 
appointed time, issue a warrant directed to the Sheriff, or any other suitable 
person, preferring some relative of the insane person when desired, command- 
ing him to arrest such person and convey him to the hospital ; and if the clerk 
is satisfied that it is necessary, he may authorize an assistant to be employed. 

Sec. 1 8. — Discharge of Patients ; Notice; Removal. 

Whenever the Trustees shall order any patients discharged, the Superin- 
tendent shall at once notify the clerk of the county court of the proper 
county thereof (if the patient is a pauper [and if not, shall notify all the per- 
sons who signed the bonds required in Section 15 of this Act] and request the 
removal of the patient) ; if such patient be not removed within thirty days 
after such notice is received, then the Superintendent may return him to the 
place from whence he came, and the reasonable expense thereof may be 
recovered by suit on the bond, or in ca>e of the pauper, shall be paid by the 
profit paid to the county. 

SEC. 20. — Restoration to Reason ; discharge. 

When any patient shall be restored to reason, he shall have the right to 
leave the hospital at any time, and if detained therein contrary to his wishes 
after such restoration, shall have the privilege and right of habeas corpus at 
all times, either on his application or that of any other person in his behalf. 
If the patient is discharged on such writ, and if it shall appear that the Superin- 
tendent has acted in bad faith or negligently, the Superintendent shall pay all 
the costs of the proceedings. Such Superintendent shall moreover be liable 
to civil action for false imprisonment. 

Sec. 22. — Trial by Jury Necessary. 

Xo Superintendent or other officer, or person connected with either of the 
State Hospitals for the Insane, or wiih any other hospital or asylum for the in- 
sane or distracted persons in this State, shall receive, detain, or keep in custody 
at such hospital or asylum, any person who shall not have been declared insane 
by the verdict of a jury and authorized to be confined by the order of a court 
of competent jurisdiction ; and no trial shall be had questioning the sanity or 



574 APPENDIX. 

insanity of any person before any judge or court, without the person being 
present alleged to be insane. 

ACTS OF INDIANA, 1881. 

Section 2835. — Duties of the Trustees. 

The Trustees shall be entrusted with the general control and management of 
the hospital. *********** 

Sec. 2837. — Proceedings. 

The Trustees shall keep a full account of their proceedings in a book to be 
provided for that purpose. The officers of the institution shall make reports 
to the Trustees as they may from time to time require. The Superintendent 
and Treasurer shall severally make full reports to be submitted at their annual 
meetings. 

Sec. 2840. — Powers and Duties. 

The Superintendent shall be the chief executive officer of the hospital, 
and shall have the care and control of everything connected therewith. He 
shall see that the several officers of the institution faithfully and diligently 
discharge their respective duties. He shall employ such attendants, nurses, 
servants, and other persons he may think proper, and assign them to their 
duties, and may at pleasure discharge them. He shall receive from the proper 
persons the patients entitled to admission in the hospital, and when cured dis- 
charge them. In all cases, however, he shall be subject to the control of the 
Trustees. 

Sec. 2841. — Reports. 

The Superintendent shall make reports to the Trustees as required by Sec- 
tion 2837. 

Sec. 2842. — Admission of Patients. 

All insane persons residing in the State of Indiana, and having legal settle- 
ment in any county therein, shall be entitled to be maintained and receive 
medical treatment in the Indiana Hospital for the Insane at the expense of the 
State. ************ 

Sec. 2844. — Examination. 

The Justice of the Peace with whom said statements shall have been filed, 
together with another Justice of the Peace and a respectable practicing physi- 
cian other than the medical attendant of the person alleged to be insane, who 
shall be elected by the aforesaid Justice of the Peace, and who shall reside in 
the proper county, shall immediately thereupon visit and examine the person 
alleged to be insane, in relation to his mental condition. 

Sec. 2847. — Medical Certificate. 

They shall require the medical attendant to make, on oath, a written state- 
ment of the medical history and treatment given to the case. 



LEGAL CARE OF THE INSANE. 575 

Sec. 2S52. — Superintendent 's Duties. 

Upon receiving said application and transcribed statements and certificates, 
the Superintendent of the Hospital for the Insane shall immediately, upon the 
information therein contained, determine whether the case is recent and pre- 
sumably curable, or chronic and less curable, cr idiotic and incurable. If the 
case be recent and curable, the Superintendent shall at once notify the proper 
clerk of the acceptance of the application for admission ; if the case be 
chronic, whether curable or incurable, an acceptance shall issue as above, 
provided that there be room in the hospital for more patients than are at pres- 
ent resident therein, together with those recently accepted but not admitted; 
otherwise the application shall be rejected. In the selection of chronic cases 
for admission, each county shall be entitled to a just proportion, according to 
its population, and priority of application shall have recognition. 

Sec. 2862. — Recurrence of Insanity. 

Any person who has ever been adjudged insane according to law, within the 
State of Indiana, and has been formally discharged from any Hospital or Asy- 
lum for the Insane within the State, shall not again be admitted to any such 
hospital or asylum " except upon the affidavit of a respectable practicing physi- 
cian of the county where the patient resides, that he knows the patient, that 
he has been adjudged insane, that he has been in a hospital, that he is insane 
and a proper subject for treatment." He must state the reasons of his opinion. 

Sec. 2863. — Discharge. 

Any patient may be discharged from the hospital by the Superintendent 
upon restoraticn to health ; and incurable and harmless patients shall be dis- 
charged whenever it is necessary to make room for recent cases. All danger- 
ous patients shall be retained in the hospital. 

CODE OF IOWA, 1889. 

Section 1395. — In each county there shall be a Board of three Commis- 
sioners of Insanity ; the Clerk of the Circuit Court shall be a member of such 
Board and clerk of the same; the other members shall be appointed by the 
Judge of said court. One of them shall be a respectable practicing physician, 
and the other a respectable practicing lawyer. ***** 

Sec. 1399. — Application for admission to the hospital must be made in the 
form of information, verified by affidavit, alleging that the person in whose 
behalf the application is made is believed by the informant to be insane and a 
fit subject for custody and treatment in the hospital; that such person is 
found in the county and has a legal settlement therein, if such is known to be 
the fact; and if such settlement is not in the county, where it is, if known, or 
where it is believed to be if the informant has advice on the subject. 

Sec. 1400. — On the filing of such information, the Commissioners may 



576 APPENDIX. 

examine the informant under oath, and if satisfied there is reasonable cause 
therefor, shall investigate the ground thereof, and for this purpose they may 
require that the person for whom admission is sought be brought before them 
and that the examination be had in his presence ; and they may issue their 
warrant therefor, and provide for the suitable custody of such person until 
their investigation shall be concluded. Such warrant may be executed by the 
Sheriff or any constable of the county; or if they shall be of the opinion from 
such preliminary inquiries as they may make — and in making which they shall 
take the testimony of the informant, if they deem it necessary or desirable, and 
of other witnesses, if offered — that such course would probably be injurious to 
such person, or attended with no advantage, they may dispense with such 
person. In their examination they shall hear testimony for and against such 
application, if any is offered. Any citizen of the county, or any relative of the 
person alleged to be insane, may appear and resist the application, and the 
parties may appear by counsel if they elect. The Commissioners, whether they 
dispense with the presence before them of such person, or not, shall appoint 
some regularly practicing physician of the county to visit such person, and 
make a personal examination touching the truth of the information, and the 
mental condition of such person, and forthwith report to them thereon. Such 
physician may or may not be one of their own number ; and the physician so 
appointed and acting shall certify, under his hand, that he has in pursuance 
of his appointment made a careful personal examination as required; and that 
on such examination he finds the person in question insane, if such is the fact; 
and if otherwise, not insane ; and in connection with his examination the said 
physician shall endeavor to obtain from the relatives of the person in question ; 
or from others who know the facts, correct answers, as far as may be, to the 
interrogatories hereinafter required to be propounded in such cases; such 
interrogatories and answers to be attached to his certificate. 

Sec. 1401. — On return of the physician's certificate, the Commissioners 
shall, as soon as practicable, conclude their investigation, and shall find whether 
the person alleged to be insane, is insane; whether if insane, a fit subject for 
treatment and custody in the hospital ; whether the alleged settlement of such 
person is in their county, and if not in their county, where it is if ascertained. 
If they find that such person is not insane, they shall order his immediate 
discharge if in custody. If they find such person insane and a fit subject for 
custody and treatment in the hospital [they shall order said person to be com- 
mitted to the hospital, unless said person so found to be insane (or some one 
in his or her behalf) shall appeal from the finding of the said Commissioners] 
they shall forthwith issue their warrant and a duplicate thereof, stating such 
finding, with the settlement of the person, if found ; and if not found, their 
information, if any, in regard thereto, authorizing the superintendent of the 



LEGAL CARE OF THE INSANE. 577 

hospital to receive and keep such person as a patient therein ; such warrant 
and duplicate, with the certificate and finding of the physician, shall be 
delivered to the Sheriff of the county, who shall execute the same by con- 
veying such person to the hospital, and delivering him, with such duplicate 
and physician's certificate and finding, to the superintendent thereof. * * 
Sec. 1424. — Any patient, who is cured, shall be immediately discharged by 
the superintendent. Upon such discharge, the superintendent shall furnish 
the patient, unless otherwise supplied, with suitable clothing and a sum of 
money not exceeding twenty dollars, which shall be charged with the other 
expenses in the hospital of such patient. The relatives of any patient not 
susceptible of cure by remedial treatment in the hospital, and not dangerous to 
be at large, shall have the right to take charge of, or remove such patient on 
consent of the Board of Trustees. In the intermediate meetings of the Board, 
the consent of two Trustees shall be sufficient. 



GENERAL STATUTES OF KANSAS, 1889. 

Section 260 (6186). — Government. 

The government of insane asylums of the State shall be vested in the Board 
of Trustees of the Institutions for * * * * insane. 

Sec. 261 (6187). — Application. 

The Board of Trustees shall designate the superintendent of one of the insane 
asylums, to whom all applications for the admission of insane persons shall be 
made ; and who, under such rules as may be made by the Board of Trustees, 
shall designate to which asylum each applicant shall be admitted. * * * 

Sec. 263 (6189). — Medical and Executive Officer. 

The superintendent shall be the executive officer of the asylum, and shall 
have control of all the affairs of the asylum, subject to the direction of the 
Board of Trustees. * * * * He shall make to the Board of 
Trustees at least semi-annual reports showing the movements of the population 
and the operations of the asylum during the period embraced therein ; and at 
the close of the biennial period, he shall report in detail the conditions of the 
asylum and all of its concerns. 

Sec. 266 (6192). — Abstract of Correspondence. 

A full abstract of all correspondence relating to the admission of patients, 
their treatment, and all other matters of an official nature and the replies 
thereto, shall be kept by the superintendent. He shall also cause to be kept a 
complete record of each case, and the treatment thereof, and prescription book, 
with the date when it was appointed and administered, and such other records 
as may be necessary to give the board and the public a full knowledge of all 
prescriptions and business of the medical department. 
49 



578 APPENDIX. 



STATE OF KENTUCKY, STATUTES, 1881. 

Chapter 73, Section 4. — Officers of the Asylum. 

There shall be for each asylum a medical Superintendent who shall be a 
skillful physician, and a steward ; and for the Eastern Kentucky Asylum a first 
and a second assistant physician ; and for the Central Kentucky Asylum one 
assistant physician. These officers shall reside in the asylum. * * * 

Sec. 5. — Duties of Medical Superintendent. 

A medical Superintendent shall have general management, supervision and 
control of patients and the asylum, subject to the regulations of the Board of 
Commissioners, and shall devote his entire time thereto. He shall keep a 
register of all patients, showing their names, ages, residences, dates of reception 
and discharge or death, by whose authority received, and whether they are pay- 
patients or paupers. 

The Superintendent shall appoint all such other inferior officers and em- 
ployees (not otherwise provided for in this act) as he may deem necessary for 
the proper management of the institution ; and he may remove any of them at 
pleasure and fill their places with others. 

Sec. 14. — Discharge of Patients. 

No private patient who has not been found to be insane by regular inquest, 
shall be received into either of the State asylums. Nor shall any patient be 
discharged as cured or delivered to the custody of friends, whose friends have 
placed him in the asylum, but by permit of the Superintendent and Com- 
missioners. Any cured patient who was committed to the asylum whilst in 
custody of the law upon a criminal charge, shall be delivered to the keeper of 
the penitentiary, or to the jailor of the county, as the case may require. 

A cured pauper before being discharged shall have a good suit of clothes, 
and be furnished with money enough to pay his traveling expenses back home, 
not exceeding twenty dollars. 

Sec. 20. — Report of Superintendent and Board. 

The Superintendent and the Board of Commissioners shall, on or before the 
1st of November of each year, make a report to the Governor of the condition 
of the asylum in their charge, * * * * number and names of patients, 
(distinguishing pauper from pay-patients and certifying the place from which 
they came), the number received and discharged each year, with such other 
facts and suggestions they may deem important, which report the Governor 
shall communicate to the Legislature at its next regular session. 

Sec. 9. — Presence of the Person Necessary. 

No inquest shall be held unless the person charged to be of unsound mind 
is in the court and personally in the presence of a jury. The personal presence 
of the person charged shall not be dispensed with unless it shall appear by the 



LEGAL CARE OF THE INSANE. 579 

oath or affidavit of two physicians that they made personal examination of the 
individual charged to be of unsound mind, and that they verily believe him to 
be an idiot or lunatic, as the case may be, and that his condition is such that it 
may be unsafe to bring him into court. 

STATUTES OF LOUISIANA, 1876. 

Section 1768. — Lunatics, How Admitted. 

Whenever it shall be known to the Judge of a district or parish court, by the 
petition on oath of any individual, that any lunatic or insane person within his 
district ought to be sent or confined in the insane asylum of this State, it shall 
be the duty of said district or parish Judge to issue a warrant to bring before 
him said lunatic or insane person, and after inquiry into all the facts and cir- 
cumstances of the case, if in his opinion he ought to be sent or confined in 
said asylum, he shall make out his warrant to the Sheriff of the parish, com- 
manding him to convey the lunatic or insane person to the insane asylum. * 
* * * 

Sec. 1776. — Examination by Physician. 

The physician of the asylum shall professionally examine the lunatic or 
insane person sent to the asylum by the authority of the district or parish Judge, 
and if in his opinion said person is only feigning insane, being a person charged 
with felonious crime, he shall report to the Board, who shall investigate the 
facts, and if in the judgment of the majority said person shall not be admitted 
as an inmate of the asylum, the President of said board shall cause said person 
feigning insanity, and who had been previously committed to prison for a crime, 
to be confined in the parish jail, and shall immediately inform the president 
of the police of the parish, or a proper authority in the Parish of Orleans, where 
the rejected person has his domicile, of the fact and the reason of his rejec- 
tion ; and the provisions of this section shall also apply to such persons charged 
with a crime who afterward recover and become sane in said asylum. 

ACTS OF LOUISIANA, 1888. 

Section i. — Postal Rights of Inmates. 

Be it enacted by the General Assembly of Louisiana, that henceforth each 
and every inmate of each and every insane asylum, both public and private, in 
the State of Louisiana, shall be allowed to choose one individual to whom he or 
she may write, when and whatever he or she desires, and over these letters to this 
individual there shall be no censorship exercised or allowed by any of the asy- 
lum officials or employees ; but their post-office privilege shall, so far as this 
one individual is concerned, be as free and unrestricted as are those of any other 
resident or citizen of the State of Louisiana, and shall be under the protection 
of the same postal laws; and each and every inmate shall have the right to 



580 APPENDIX. 

make a new choice of this individual every three months if he or she so desires ; 
and it is here made the duty of the Superintendent to furnish each and every 
inmate of every insane asylum in this State, either public or private, with 
suitable material for writing, inclosing, sealing, stamping, and mailing letters, 
sufficient at least for the writing of one letter a week, provided they request the 
same, unless they are otherwise furnished with such material ; and all such let- 
ters shall be dropped by the writer thereof, accompanied by an attendant When 
necessary, into a post-office box of the State at the insane asylum and kept in 
some place easy of access to all patients. * * * * * * 



STATUTES OF MAINE, 1883. 

Section i. — Government of the Asylum. 

The government of the Maine Insane Hospital is vested in a committee of 
six Trustees, one of whom shall be a woman. * * * * * * 

Sec. 4. — The Trustees may Examine and Discharge Patients. 

There shall be a thorough examination of the hospital monthly by two of 
the Trustees, quarterly by three, and annually by a majority of the full Board; 
and at any other time when they deem it necessary or the Superintendent re- 
quests it. At each visit a written account of the state of the institution shall 
be drawn up by the visitors, recorded, and presented at the annual meet- 
ing of the Trustees, at which meeting they, with the Superintendent, shall make 
a particular examination of the condition of each patient, and discharge any 
one so far restored that his comfort and safety and that of the public no longer 
require his confinement. ■£#■£•*##■*## 

Sec. 7. — Duties and Powers of the Superintendent. 

The Superintendent shall be the physician, reside constantly at the hospital, 
have general superintendence of the hospital and grounds, receive all pa- 
tients legally sent to the hospital, unless the number exceeds its accommodation, 
and have charge of them, and control of all persons therein, subject to the 
regulations of the Board of Trustees ; and annually on the last day of Novem- 
ber report to the Trustees the condition and prospects of the institution, with 
such remarks and suggestions relative to its management and the general sub- 
ject of interest as he thinks will promote the cause of science and humanity. 

Sec. 29. — Rules Should be Kept Posted. 

The Superintendent shall keep posted, in conspicuous places about said hos- 
pital, printed cards containing the rules prescribed for the government of the 
attendants in charge of patients. 

Sec. 34. — Certificate of Physician. 

In the case of preliminary proceedings for the commitment of an insane per- 
son to the hospital, the evidence and certificate of at least two respectable 



LEGAL CARE OF THE INSANE. 58 1 

physicians, based upon due inquiry and personal examination of the person to 
whom insanity is imputed, shall be required, to establish the fact of insanity, 
and a certified copy of the physician's certificate shall accompany the person 
to be committed. 

Sec. 36. — Postal Rights of the Inmates. 

The names of the Committee of Examiners and the post-office address of 
each shall be kept posted in every ward of the hospital, and every inmate shall 
be allowed to write when and whatever he pleases to them or either of them, 
unless otherwise ordered by a majority of the committee in writing, which 
order shall continue in force until countermanded in writing by said committee. 
For this purpose every patient not otherwise ordered as aforesaid shall be fur- 
nished by the Superintendent, on request, with suitable materials for writing, 
enclosing, and sealing letters. The Superintendent shall provide, at the expense 
of the State, securely locked letter boxes, easily accessible to all inmates, to be 
placed in the hospital, into which such letters can be dropped by the writer. 
No officer, attendant, or employee of the hospital shall have the means of 
reaching the contents of these boxes, but the letters in them shall be collected 
weekly by some member of the committee, or by such person as the committee 
authorizes for the purpose, who shall prepay such only as are addressed to 
some of the committee, and deposit them in the post-office without delay. 

LAWS OF MARYLAND, 1888. 

Section i. — When any person is alleged to be a lunatic or insane, the Cir- 
cuit Court of the county in which such person may reside, or a Criminal Couit 
of Baltimore (if such person reside in the city of Baltimore), shall cause a jury 
of twelve good and lawful men to be impanneled forthwith, and shall charge the 
said jury to inquire whether such person is insane or lunatic; and if found so 
it shall be the duty of the court to cause such person to be sent to the alms- 
house of the county, or to a hospital, or to some other place better situated in 
the judgment of the court for his condition, there to be confined at the expense 
of the county or State until he shall recover and be discharged in due course 
of law. -a-****-***-**** 

Sec. 26. — The Superintendent, or other officer or keeper of any institution, 
public, corporate, or private, or almshouse, where the insane may be kept, 
shall be required to keep a record of all patients in such form as the Com- 
missioners shall direct; also a record in which shall be entered the incidents 
and accidents that may occur ; also the number and kinds of restraints used, 
with details of them, to be reported to the Commissioners. 

Sec. 30. — The Board of Managers, or Superintendent of any institution, 
public, corporate, or private, or almshouse, which may be duly authorized to 
hold in custody any insane person in accordance with the law, may appoint 



582 APPENDIX. 

one or more attendants or other employees of such places, as policeman 
or policemen, whose duty it shall be, under the orders of said Superintendents 
or manager, or keeper, to arrest and return to such asylum, or other institution 
for the treatment of the insane, or insane persons who may escape therefrom. 

Sec. 31. — No person shall be put or confined as a patient in any institution, 
public, corporate, or private, or almshouse, or other house for the care and cus- 
tody of the insane or idiotic, except upon the rendering of a certificate of two 
qualified physicians, made within one week after the examination by them of 
said alleged lunatic, and setting forth the insanity or idiocy of such person, 
and the reason for such opinion. * * * * * * * 

Sec. 33. — The Superintendent or other officer of any asylum or other 
institution where the insane are kept in custody or received for treatment, 
whether public, corporate, or private, or almshouse, shall within ten days after 
the reception of such patient or person make, or cause to be made, a descrip- 
tion of such case in a book kept exclusively for the purpose ; they shall aLo 
make entries from time to time of the mental condition of such patient or 
person so confined. 

Sec. 35. — Every person confined in such place as hereinbefore mentioned, 
shall be furnished at all times with paper, envelopes, stamps, pen and ink, or 
pencil ; shall at all times have access for correspondence with the lunacy com- 
mission, and some one other person whom such lunatic may designate every 
month, under seal, which communication shall be forwarded by the officer, 
Superintendent, or keeper, who may be in charge of such person or place. * 



ACTS OF MASSACHUSETTS, 1882. 

Chapter 87. — Section ii. — Judges may commit Insane Persons to the 
State Hospital. 

A Judge of the Supreme Judicial Court or Superior Court of any county, or 
a Judge of a Probate Court, or of a Police or District or Municipal Court 
within this county, may commit to either of the State Lunatic Asylums any 
insane person, when residing or being in said county, who in his opinion is a 
proper subject for its treatment or custody. 

Sec. 12. — No Person to be Committed to any Hospital Without Order of 
the Judge. 

Except when otherwise specially provided, no person shall be committed 
to the lunatic hospital or other receptacle for the insane, public or private, 
without the order or certificate therefor signed by one of the Judges named 
in the preceding section, said person residing or being within the county as 
herein provided. Such order or certificate shall state that the Judge finds the 
person committed is insane, and is a fit person for the treatment of the insane 



LEGAL CARE OF THE INSANE. 583 

asylum. The said Judge shall see and examine the person alleged to be insane, 
or state in his final order why he did not deem it necessary or advisable to 
do so. **■*■*•**■*■*•**■** 

Sec. 13. — Certificate of Two Physicians. 

Xo person shall be committed unless, in addition to the formal testimony, 
there has been filed with the Judge a certificate signed by two physicians, each 
one of whom is a graduate of some legally organized medical college, and has 
practiced three years in the State, and neither of whom is connected with any 
hospital or other establishment for treatment of the insane. Each must have 
personally examined the person alleged to be insane within five days of signing 
the certificate, and each shall certify that in his opinion said person is insane 
and a proper subject for treatment in the insane hospital, and shall specify the 
facts on which his opinion is formed. A copy of the certificate, attested by 
the Judge, shall be delivered by the officer or other person making the com- 
mitment, to the Superintendent of the hospital, or other place of commit- 
ment, and shall be filed and kept with the order. 

Sec. 15. — Statement Regarding Insane Person to be Filed with the Judge ; 
Duty of the Superintendent. 

Upon every application for the commitment or admission of any insane person 
to a hospital or asylum for the insane, there shall be filed with the application, 
within ten days after the commitment or admission, a statement in respect to such 
person, showing as near as can be ascertained his age, birthplace, exact condi- 
tion, place, and occupation ; the supposed cause and duration and character 
of his condition, whether mild, violent, dangerous, homicidal, suicidal, para- 
lytic, apoplectic, the present symptoms of insanity in the person or his family, 
his habits in regard to temperance ; whether he has been in a lunatic asylum 
or hospital, and if so, what one, when, how long; and if the patient is a 
woman, whether she has borne children, and if so, what time had elapsed 
since the birth of the youngest; the names and addresses of his father, mother, 
children, brother, sister, or others next of kin, not exceeding ten in number 
and over eighteen years of age, when the names and addresses of such relatives 
are known by the person or persons making such application, together with 
any fact showing whether he has or has not a settlement, and if he has 
a settlement, in what place ; and if the applicant is unable to state any of the 
above particulars, he shall state his inability to do so. The statement, or a 
copy thereof, shall be transmitted to the Superintendent of the hospital or 
asylum, to be filed with the order or application for admission. The Superin- 
tendent shall, within two days of the time of admission or commitment of the 
insane person, send, or cause to be sent, notice of said commitment, in writing, 
by mail, postage prepaid, to each of said relatives, and to any other two persons 
whom the person committed shall designate. 



584 APPENDIX. 

Sec. 26. — Persons Violently Insane may be Received at the Hospital With- 
out Warrant of Commitment. 

The Superintendent or keeper of a hospital, including the McLean Asylum 
at Somerville, may receive into his custody, and detain in such hospital or 
asylum for a period not exceeding five days, without an order of the Judge, 
as provided in Section 2, any person as insane, whose case is duly certified to 
be one of violent and dangerous insanity and emergency by two physicians 
qualified as in Section 13. In addition to such certificates an application 
signed by one of the Selectmen of the town, or by one of the Aldermen of the 
city in which such insane person resides or is found, shall be left with the 
Superintendent of the hospital or asylum in which the insane person is 
received, and such application shall contain the statement in respect to such 
insane person which is required by Section 15, and a further statement that 
the case is one of violent and dangerous insanity. 

Sec. 29. — Notice to be Given to the Board of Health, Lunacy, and Charity. 

When the patient is received into such hospital upon his own application or 
under the provisions of Section 26, the Superintendent thereof shall give im- 
mediate notice of such reception to the State Board of Health, Lunacy, and 
Charity, stating all the particulars, including the legal settlement of the person 
so received, if known; the State Board shall immediately cause such cases 
to be investigated and a record be made of all the facts pertaining thereto. 

Sec. 35. — Certain Privileges of Patients in Hospitals. 

An attorney regularly retained by or on behalf of any person committed to 
a lunatic hospital, asylum, or receptacle for the insane, shall be admitted to 
visit such client at all reasonable times, if in the opinion of the superin- 
tending officers of such hospital, asylum, or receptacle such visit would not 
be injurious to such person, or if a Judge of the Supreme Judicial Court, 
Superior Court, or Probate Court in any county first orders, in writing, that 
such visits be allowed. 

Sec. 36. — Postal Privileges of Patients. 

The patients in the lunatic hospital, asylum, or receptacle for the insane, shall 
be allowed to write monthly to the Superintendent or to the State Board, 
and they shall be furnished by the Superintendent with all materials necessary 
for such correspondence ; and a letter-box shall be placed in each ward in 
which each writer may deposit his letters, and the box shall be opened and 
the letters distributed monthly by the said Board. 

ACTS OF MASSACHUSETTS, 1883. 

Section i. — Discharge of Inmates from Lunatic Asylum by Superin- 
tendent. 

The Board of Trustees of the State Lunatic Asylums, or of the Massachu- 



LEGAL CARE OF THE INSANE. 585 

setts General Hospital, may by vote confer on the Superintendent of the hos- 
pital or asylum under their control, authority to discharge therefrom any 
inmate thereof committed thereto as an insane person, provided due written 
notice of intention so to discharge shall be sent by said Superintendent to the 
person or persons who originally sent the petition for the commitment of 
such inmate. 

Sec. 2. — Temporary absence from the Hospital by the Permission of the 
Superintendent. 

Said Superintendent may also, when he shall deem it advisable, permit any 
such inmate to leave the hospital or asylum temporarily, in charge of his 
guardian, relatives, or friends, for the period not exceeding sixty days, and 
receive him when returned by such guardian, relatives, or friends within such 
period without further order. 



PUBLIC ACTS OF MICHIGAN, 1885. 

Section i. — * * * The asylums for the insane of the 
State of Michigan shall be under the control of separate Boards of Trustees. 

Sec. 5. — Appointment of the Superintendent * * * Stewrad, 
and Assistant Medical Superintendent. * * * 

The Board of Trustees shall severally appoint a Medical Superintendent, 
who shall be a well-educated physician, experienced in the treatment of the 
insane ; and a Treasurer, not one of their number, who shall give bonds for 
the performance of his trust, in such sum and with such sureties as the Direc- 
tor-General of the State shall approve. They shall also appoint, upon the 
nomination of the Medical Superintendent, a Steward, and a Chaplain ; and 
also in a like manner an Assistant Medical Superintendent, and necessary 
assistant physicians. All medical officers shall resTde at the asylum. * * 

Sec. 12. — Powers and Duties of the Medical Superintendent. 

The Medical Superintendent shall be the chief executive officer of the 
asylum. He shall have the general superintendence of the buildings, grounds, 
and farm, together with the furniture, fixtures, and stock; and the direction 
and control of all persons therein, subject to the by-laws and regulations 
established by the Trustees. He shall daily ascertain the condition of all 
patients, and prescribe for their treatment in the manner directed in the by- 
laws. He shall have the nomination of his coresident officers, with power to 
assign them to their respective duties, subject to the by-laws ; also to appoint, 
with the approval of the Trustees, such and so many other assistants and 
attendants as he may think necessary and proper for the economical and 
efficient performance of the business of the asylum, and to prescribe 
their several duties and places, and fix, with the approval of the Trustees, 
5o 



586 APPENDIX. 

their compensation, and to discharge any of them at his will and 
discretion ; but in eveiy case of discharge he shall forthwith record the same, 
with the reasons of discharge, under a proper head in one of the books of the 
asylum. He shall also have the power to suspend until the next meeting of 
the Trustees, for good and sufficient cause, a resident officer; but in such case 
he shall forthwith give written notice of the fact, with its cause and circum- 
stances, to one of the Trustees, whose duty thereupon shall be to call a special 
meeting of the Board to provide for the exigency. He shall also from time to 
time give such orders and instructions as he may judge best calculated to 
ensure good conduct, fidelity, and economy in every department of labor and 
expense; and he is authorized and enjoined lo maintain well-directed discipline 
among all who are employed by the institution ; and lo enforce direct compli- 
ance with such instructions, and uniform obedience to all rules and regulations 
of the asylum. He is authorized and directed to use every proper means to 
furnish employment to such patients as may be benefited by regular labor 
suited to their capacity and strength. He shall further cause full and fair 
accounts and records of all his doings and the entire business and operations of 
the institution, to be kept regularly from day to day, in bcoks provided for that 
purpose in the manner and to the extent prescribed in the by-laws; and he 
shall see that all such accounts are fully made up to the last day of September 
immediately preceding the meeting of the Legislature, and that the principal 
facts and results, with his reports thereon, be at the time presented to the 
Trustees. It shall be the duty of the Medical Superintendent to admit any 
member of the Board of Trustees in every part of the asylum, and to exhibit 
to him or them on demand, all the books, papers, and accounts and writings 
belonging to the institution or pertaining to its business, management, disci- 
pline, or government ; also to furnish copies of abstracts and reports whenever 
required by the Board. Trie Medical Superintendent shall make, in a book 
kept for that purpose, at the time of reception, a minute with date of same, the 
name, residence, office, and occupation of the person, by whom and by whose 
authority each insane person is brought to the asylum ; and shall have all the 
orders, warrants, requests, certificates, and other papers accompanying him, 
forthwith filed. The Assistant Medical Superintendent shall perform the 
duties and be subject to the responsibility of the Medical Superintendent in 
his sickness or absence. 

LAWS OF 1S89. 

SECTION 21. — Certificate of Admission of Patients. * * * Duty 
of Medical Superintendent to notify Judge, etc. 

No person shall be admitted or held as a private patient in any asylum, public 
or private, or any institution, home, or retreat, for the care or treatment of insane, 
except upon the ceitificale of two reputable physicians under oath, appointed 



LEGAL CARE OF THE INSANE. 587 

by the Judge of Probate Court where such alleged insane person resides, to 
conduct an examination, and an order from the said Judge of the Probate 
Court setting forth that the said person is insane, and directing his removal to 
an asylum or institution for the care of insane ; no person shall be held in con- 
finement in any such asylum or institution for more than fourteen days with- 
out such certificate or order. 

Sec. 22. — Qualifications of Physicians certifying to Insanity ', etc. 

It shall not be lawful for any physician to certify to the insanity of any per- 
son for the purpose of securing his admission to an asylum, unless such physi- 
cian be of reputable character, and graduate of some incorporated medical 
college, a permanent resident of the State, registered according to law, not 
related by blood or marriage to the alleged insane person nor to the person 
applying for such certificate, and shall have been in actual practice of his pro- 
fession for at least three years; and such qualification shall be certified to by 
the clerk of the county in which such physician resides. No certificate of 
insanity shall be made except under the personal examination of the party 
alleged to be insane ; and it shall not be lawful for any physician to certify to 
the insanity of any person for the purpose of committing him to an asylum for 
which the said physician is either a trustee or a superintendent, proprietor, 
an officer, or a regular professional attendant. * * * * * 

Sec. 37. — * * * Report by the Medical Superintendent of 
the Insane Asylum. * * * * 

* * * The Medical Superintendents of the several insane asylums 
shall report quarterly to the Secretary of the Board of Corrections and Charities, 
the names and ages of all patients supported at State or county charge ; * * 
and shall also report to the Secretary of the Board of Corrections and Charities 
the date and circumstances attending the discharge, removal, elopement, or 
death of all insane persons received, aided or supported at County or State 
charge ************ 

Sec. 38. — * * * Preference in Admission, etc., when lack of 
Room for All. 

* * * In case the Superintendents of the asylums find it impossi- 
ble to receive all patients for whom application is made, they may, at their 
discretion, give preference to those for whom, in their judgment, treatment is 
most urgently necessary. To make room for urgent cases they are also author- 
ized to order the removal from the asylum to his home and friends, or to the 
Superintendent of the Poor of the county whence he came, of any patient 
that in their judgment may safely reside outside of the institution. 

Sec. 47. — Definition of Terms " Insane*' and '* Insane Persons." 
The terms "insane" or "insane person," as used in this act, include every 
species of insanity and extend to every derangement of persons, and to all of 
unsound mind other than idiots. ******** 



588 APPENDIX. 



GENERAL ACTS, MINNESOTA, 1887. 

Chapter 146. — Section i. — Postal Rights of Insane Persons. 

That henceforth each and every inmate of each and every insane asylum, 
both public and private, in the State of Minnesota, shall be allowed to choose 
one individual from the outside world, to whom he or she may write, when and 
whatever he or she may desire, and over these letters to the individual there 
shall be no censorship exercised or allowed by any of the asylum officials or 
employees. But their postal rights, so far as this one individual is concerned, 
shall be as free and unrestricted as are those of any resident or citizen of the 
State of Minnesota, and shall be under the protection of the same postal laws; 
and each and every inmate shall have the right to make a new choice of his 
individual party every three months, if he or she so desires to do; and all such 
letters shall be dropped by the writer thereof, accompanied by an attendant 
when necessary, into a post-office box provided by the State at the insane 
asylum, and kept in some place easy of access to all the patients. The 
attendant is required, when necessary, to see that this letter is directed to the 
patient's correspondent, and if it is not so directed, it must be held subject to 
the Superintendent's disposal, and the contents of the box shall be collected 
once every week by the authorized person from the Post Office Department, 
and by him placed into the hands of the United States mail for delivery. 

Sec. 2. — Duties of the Superintendent of the Insane Asylum. 

That it is hereby made the duty of the Superintendent to keep registered and 
posted in some public place at the insane asylum, a copy of the names of every 
individual chosen as an inmate's correspondent, and by whom chosen, and it is 
hereby made the duty of the Superintendent to inform each of the individuals 
named of the party choosing him or her, and he is to request him or her to 
write his or her own name on the outside of the envelope of every letter he or 
she writes to this individual inmate; and all these letters bearing the individual 
writer's name on the outside he is requested to deliver, or cause to be delivered 
any letter or writing to him or her directed, without opening or reading the 
same, or allowing it to be opened or read, unless there is reason for believing 
the letter contains some foreign substance which may be used for medication ; 
in which case the letter shall be required to be opened in the presence of a 
competent witness, and this substance shall be delivered to the Superintendent 
to be used at his discretion. 

Sec. 4. — Superintendent to Provide Registers and Stationery. 

It shall be the duty of the Superintendent of each hospital or asylum for 
insane to furnish each assistant physician with a pocket register of correspond- 
ence, in such way as the State Department of Corrections and Charities may 
prescribe, and to keep on hand some envelopes, paper, and postal-cards, which 
shall be used for each correspondent. Such registers and stationery shall be 



LEGAL CARE OF THE INSANE. 589 

furnished on requisition of the assistant physicians, and shall be paid for from 
the current expense funds of such institution. ****** 

Whenever any letter or postal card from any correspondent chosen under 
this act shall be delivered to any assistant physician by the Superintendent, he 
shall deliver the same to the inmate to whom it is addressed, without unnec- 
essary delay, taking the receipt of said inmate therefore. 

Sec. 6. — The Superintendent to Mail and Deliver Letters. 

* * * It shall be the duty of the Superintendent, upon receipt 
of such letters from the assistant physician, if he shall find that the said 
letter is addressed to a correspondent duly chosen under this act, to place 
such letter, or cause it to be placed, in the United States mail without open- 
ing or reading the same. It shall be the duty of the Superintendent to request 
the said correspondents to write their names on the outside of the letters 
sent by them to the inmates. The said Superintendent shall deliver such 
letters to the assistant physician to be given to the inmates to whom they 
are addressed, unless in the judgment of the said Superintendent the receipt 
of such letters would be injurious to such inmates, in which case they shall 
forthwith notify such correspondents that such letters are withheld, stating 
the reasons therefor, and recording the fact in the register of correspon- 
dence. No letter written by a correspondent to an inmate shall be opened by 
any Superintendent, unless he has reason to suspect that it contains such 
matter as ought not to be delivered to said inmate, in which case he shall 
record the fact that such letter has been opened, and the reasons therefor, in the 
register of correspondence. 

Sec. 7. — Inmates may Correspond with the Governor and the Secretary of 
the State Board of Corrections and Charity. 

* * * * Each and every inmate of any hospital for the insane 
in the State shall have tha privilege of communicating in writing with the 
Governor and the Secretary of the State Board of Corrections and Charities, in 
the same manner, under the same regulations, as with the correspondents chosen 
under this act. 

Chapter XIV. — Sec. 267. — Physician to Examine Alleged Insane Person. 

Upon the filing of information the court shall make an order directed to 
two (2) persons, one of whom at least shall be a duly qualified physician, 
and such persons, in connection with the Judge of Probate, shall constitute a 
jury to examine the person alleged to be insane, and they shall ascertain the 
fact of sanity or insanity. 

Sec. 274. — When Discharged, Probate Court to be Notified. 

When any person, who has been committed to the care and custody of the 
Superintendent of the hospital by warrant of the Probate Court, shall be dis- 
charged from such hospital, the Superintendent shall, upon day of such dis- 



590 APPENDIX. 

charge, send by mail to the Judge of Probate of the county in which such 
warrant was issued a certificate signed by him, stating that the person has 
been discharged from such hospital, and the date of such discharge, which 
certificate shall be filed in the Probate Court. 



CODE OF MISSISSIPPI, 1880. 

Section 665. — The Medical Superintendent shall have power to appoint 
and remove all subordinate officers and employees allowed by the Trustees, 
and he shall make, in a book kept for that purpose, at the time of reception, a 
minute with the date of reception, with nxrae, age, sex, residence, office 
or occupation of the person, and by whom and by whose authority each 
insane person is brought to the asylum, and have all orders, warrants, 
requisitions, certificates, and other papers accompanying him or her, carefully 
filed, and have them copied in said book. * * * * He shall 
ascertain the condition of the patients, and prescribe their treatment in the 
manner prescribed in the said by-laws; and he shall also be required to 
see that all the rules and regulations for the discipline and good government 
of the institution are properly obeyed and enforced. 

Sec. 659. — Any person, being a lunatic and resident of the State of Missis- 
sippi, shall be admitted into the asylum free of charge. * * * * 

Sec. 660. — It shall be the duty of the Superintendent to admit into the asylum 
all persons ordered to be placed therein after an inquest of lunacy in the due 
order of registration, if there be a vacancy in such asylum, on the presenta- 
tion of a duly certified copy of such order under the seal of Chancery Court, 
showing thereby admission of the patient to the asylum. 

Sec. 661. — On application in behalf of any person being a lunatic and a 
resident of this State, for his or her admission into the asylum, the Superin- 
tendent and Board of Trustees may, if they think he or she ought to be 
admitted, receive him or her as a patient therein, even though no proceedings 
in lunacy have been instituted as hereinafter provided for. 

Sec. 663. — In cas2 the friends or relations of any lunatic shall neglect 
or refuse to place him or her in said asylum, and shall permit him or her to 
go at large, it shall be the duty of the clerk of the Chancery Court of any 
county in which such lunatic may reside or be found going at large, on 
the suggestion, in writing, of any citizen of the county, to direct the Sheriff, by 
writ of lunacy, to summon as soon as may be the alleged lunatic and six dis- 
creet persons of the county in which such lunatic is going at large, to make 
inquisition thereto on oath, and the result of such inquisition to be returned to 
the said court forthwith ; and if the person said to be a lunatic shall be ad- 
judged by such inquest, or a majority of them, to be insane, and one who should 



LEGAL CARE OF THE INSANE. 59 1 

be confined therein, the said clerk shall order said Sheriff to arrest said lunatic, 
and place him or her in said asylum if there be a vacancy, or if there be no 
vacancy to confine such lunatic in the county jail until room can be had in the 
lunatic asylum, -a-********** 



REVISED STATUTES OF MISSOURI, 18S9. 

Section 471. — Superintendent' 's Duties. 

The Superintendent shall be a physician of knowledge, skill, and ability 
in his profession, and hive experience in the management and treatment of 
insane ; he shall not, while such Superintendent, engage in the practice of 
his profession, but shall, to the exclusion of all other business, devote himself 
to the supervision and care of the asylum and its inmates. Before entering 
on the duties of his office he shall take an oath or affirmation that he will 
diligently, faithfully, and impartially discharge all the duties required of him 
by the law. 

Sec. 473. — Patients, How Admitted and Discharged. 

Persons afflicted with any form of insanity may be admitted into the asylum 
when the Superintendent deems it probable that their condition can be im- 
proved by the care and treatment of the institution ; and any person may be 
discharged by the Superintendent whenever he may believe that the condition 
of such person cannot be improved by a longer stay in the asylum. 

Sec. 478. — Pay Patients, How Admitted. 

Pay patients, or those not sent to the asylum by order of the court, may 
be admitted on such terms as shall be by this chapter, and the by-laws of the 
asylum, prescribed and regulated. 

Sec. 479. — Terms of Admission. 

Preparatory to the admission of such a patient the Superintendent shall be 
furnished with a request : * * * stating his age and place of 
nativity if known, his Christian and surname, place of residence, occupation, 
and degree of relationship, or any circumstances of connection between him 
and the person requesting his admission ; and a certificate * * 

dated within two months, under oath, signed by two physicians, of the fact of 
his being insane. Such person signing such request or certificate shall annex 
to his name his profession or occupation, and the township, county, and State 
of residence, unless these appear on the face of the document. Before any 
probate patient shall be received into the asylum, there shall be produced to 
the Superintendent a receipt from the Treasurer of the asylum, acknowledging 
the payment to him of at least thirty days' charge in advance, and sufficient 
bond to the said Treasurer conditioned with the obligees to secure the payment 
of the charges incurred in behalf, on account, of said patient; * * * 



59 2 APPENDIX. 

No board constituting thirty days' payment shall be refunded if a patient mak- 
ing such payment shall be taken away within the period uncured, and against 
the consent of the Superintendent. 

REVISED STATUTES, 1889. 

Chapter 86. Section 5513.— On Information, Probate Court to Inquire 
as to Sanity. 

If any information in writing be given to the Probate Court, that any person 
in its county is an idiot, lunatic, or person of unsound mind, and incapable of 
managing his affairs, and pray that an inquiry thereinto be had, the court, if 
satisfied that there is good cause for the exercise of its jurisdiction, shall cause 
the facts to be inquired into by a jury. 

Sec. 5550. — To be Discharged, When. 

If it be found that such person has been restored to his right mind, he shall 
be discharged from the care and custody, and the guardian shall immediately 
settle his accounts and restore to his person the things remaining in his hands 
belonging or pertaining to him ; and if it be found that such person has not 
been restored to his right mind, the person at whose instance the inquiry was 
had, may, in the discretion of the court, be required to pay the cost of pro- 
ceeding. 

STATUTES OF MONTANA, 1887. 

Section 121 5. — Examination of Person Alleged to be Insane. 

From and after the passage of this article it shall be the duty of the Probate 
Judge, or in his absence or incapability to act, the chairman of the Board of 
County Commissioners of the several counties of this territory, upon the appli- 
cation of any person under oath, setting forth that any person by reason of 
insanity is unsafe to be at large or is suffering under mental derangement, to 
cause said person to-be brought before him, at such time and place as he may 
direct, and the said Judge or Commissioner shall also cause to appear, at the 
same time and place, a jury of three persons of his county, one of whom shall be 
a licensed practicing physician, who shall proceed to examine the person alleged 
to be insane, and if such jury after careful examination shall certify upon oath 
that the charged is a lunatic, and the said Judge or Commissioner is satisfied that 
such person by reason of insanity is unsafe to be at large, or is incompetent to pro- 
vide for his or her own proper care and support, and has no property available 
for that purpose, and has no kindred in the degree of husband or wife, father 
or mother, children, or brother or sister, living within the territory, of sufficient 
means and ability to provide for such care and maintenance, or if he or she hav- 
ing kindred within the territory and such kindred fail or refuse to properly care 
for and maintain such insane person, such Judge or County Commissioner 



LEGAL CARE OF THE INSANE. 593 

shall make out a duplicate warrant recitirg such facts, and place them in the 
hands of the Sheriff of said county, who shall immediately in compliance there- 
with have the person or persons therein named apprehended, and deliver him 
or her or them to the director aforesaid, at the place designated in the noti- 
fication. * * * . * * 

Sec. 1227. — Inmates may be Discharged upon Report of Physician. 

The Governor shall direct and have discharged from the insane asylum 
any of the inmates thereof at any time when, from the written report to him by 
the physician in charge of said asylum, or either of them, or from any physician 
who shall be appointed to visit ar.d examine said institution, he believes such 
discharge should be granted ; provided that the report upon which he may act 
shall be filed and kept in his hands. 

Sec. 1230. — Inmates of an Asylum may Choose Confidential Correspondent. 

* * * Each and every inmate of each and every asylum, both 
public and private, shall be allowed to choose one individual from the outside 
world, to whom he or she may write when and whatever he or she desires; 
and over these letters to this individual there shall be no censorship exercised 
or allowed by any one of the asylum officials or employees; but their post-office 
rights so far as this one individual is concerned, shall be as free and unre- 
stricted as those of any other resident or citizen of the Territory of Montana, 
and shall be under the protection of the same postal laws ; and each and every 
inmate shall have the right to make a new choice of this individual party 
every three months if he or she desires to do so; and it is here made the duty 
of the Superintendent to furnish each and every inmate of every insane asylum 
in this territory, either public or private, with suitable material for writing, 
enclosing, sealing, stamping, and mailing letters, sufficient at least for the writ- 
ing of one letter a week, provided they request the same, unless they are 
otherwise furnished with such materials, and all such letters shall be dropped 
by the writers thereof, accompanied by an attendant, into the post-office box 
provided by the Department at the insane asylum, and kept in some- place easy 
of access to all the patients; the attendant is required in all cases to see that 
this letter is directed to the patient's correspondent, and if it is not so directed, 
it must be held subject to the Superintendent's disposal, and the contents of 
this box shall be collected once every week by an authorized person from the 
Post-office Department, and by him placed in the hands of the United Stales 
mail for delivery. 

Sec. 1 23 1. — Lists of Correspondents to be Registered and Posted. 

That it is hereby made the duty of the Superintendent to keep registered 
and posted in some public place at the insane asylum a true copy of the names 
of every individual chosen as the inmate's correspondent, and by whom chosen ; 
and it is hereby made the duty of the Superintendent to inform each of the in- 



594 APPENDIX. 

dividuals of the name of the party choosing him- or her, and to request him or 
her to write his or her name on the outside of the envelope of every letter he 
or she writes to this individual inmate ; and all these letters bearing individual 
writers' names on the outside, he is requested to deliver, or cause to be delivered 
any letter or writing to him or her directed, without opening or reading the 
same, or allowing it to be opened or read, unless there is reason for suspecting 
that the letter contains some foreign substance which might be used for medica- 
tion, in which case the letter shall be required to be opened in the presence of 
competent witnesses, and this substance shall be delivered to the Superin- 
tendent to be used at his discretion. 

NEBRASKA COMPILED STATUTES, 1887. 

Section 2. — Post Office Privileges of Inmates. 

* * * Henceforth there shall be no censorship exercised over the 
correspondence of the inmates of the hospital for the insane in this State, but 
their post-office rights shall be as free and unrestricted as are those of any 
resident or citizen of this S:ate, and be under the protection of the same postal 
laws, and every inmite shall be allowed to write when and whatever he or she 
desires to any person he or she may choose. And it is hereby made the duty 
of the Superintendent to furnish each and every inmate of each and every 
insane asylum in this State with suitable material, at the expense of the State, 
for writing, enclosing, sealing, stamping, and mailing letters, sufficient for 
writing at least one letter a week, provided they request the same, unless they are 
otherwise furnished with such material. * * * * * * 

Sec. 1 1 . — Duties and Power of the Superintendent. 

The Superintendent of said institution shall be a physician of acknowledged 
skill and ability in his profession, and be a graduate of a regular m;dical 
college. He shall be the chief executive officer of the hospital, and shall hold 
his office for the term of six years, unless sooner removed by the Governor, or 
for malfeasance in office, or other good and sufficient cause. He or the 
assistant physician must be in daily attendance at the hospital, and in no 
instance must they both be absent at the same time. Before entering upon 
the duties of his office, he shall take and prescribe an oath for the faithful and 
diligent discharge of the duties required by law. He shall have the entire 
control of the medical, moral, and dietetic treatment of patients, and shall see 
that the several officers of the institution faithfully and diligently discharge 
their respective duties. He shall employ attendants, servants, nurses, and 
such persons as he may deem necessary for the efficient and economical 
administration and government of the asylum- 

Sec. 21. — Application for Admission to the Hospital. 

Application for admission to the hospital must be made in writing in the 



LEGAL CARE OF THE INSANE. 595 

nature of information validified by affidavit ; such information must allege 
that the person in whose behalf the application is made is believed by 
the informant to be insane and a fit subject for custody and treatment 
in the hospital ; that such person is found in the county and has an 
alleged settlement therein, if such is known to be the fact, and if such settle- 
ment is not in the county, where it is, if known, or where it is believed to be, 
if the informant is advised on the subject. 

Sec. 12. — Investigation of the Commissioners . 

On the filing of any information as above provided, the commissioners shall 
at once take steps to investigate the grounds of the information. For this 
purpose they may require that the person for whom such admission is sought 
be brought before them and that the examination be had in his or her presence. 
* * * * The commissioners, whether they decide to dispense 
with the presence of such person or not, shall appoint some legally practicing 
physician of the county to visit or see such person, and make a personal exam- 
ination touching the truthfulness of the allegation in the information, and 
adjudge the actual condition of such person, and forthwith report to them 
thereon; and said physician may or may not be of their own number; and the 
physician so appointed and acting shill certify in his own hand that he has, 
in pursuance of his appointment, made a careful personal examination as 
required ; and that on such examination he finds the person in question insane, 
if such is the fact; and if otherwise, not insane; and in connection with his 
examination the said physician shall endeavor to obtain from the relatives of 
the person in question, or from others who know the facts, correct answers so 
far as made in the interrogatories hereinafter required to be propounded in such 
cases, which interrogations and answers shall be attached to the certificate. 

STATUTES OF NEVADA, 1889. 

Chapter 39. — Section i. — Whenever by reason of absence of the District 
Judge of the county an insane person cannot be brought before him for exam - 
ination, he may betaken before the county clerk of such county, and thereupon 
said county clerk shall be vested with the power to hold such examination, and 
discharge such person or commit him to the insane asylum in the same manner 
as may be done by the District Judge. 

GENERAL STATUTES, 1885. 

Section 1457. — District Judge to Examine Insane Person; Physician to 
Attend. 

The District Judge of any judicial district in this S:ate shall, upon applica- 
tion under oath, setting forth that a person by reason of insanity is dangerous 
to be at large, cause any person to be brought before him, and he shall summon 



Sg6 APPENDIX. 

to appear, at the same time and place, two or more witnesses having had fre- 
quent intercourse with the accused during the time of alleged insanity, who 
shall certify under oath as to conversation, manners, and general conduct upon 
which said charge of insanity is based ; and he shall also cause to appear 
before him at the same time and place two graduates in medicine, before whom 
the District Judge shall summon a jury, and if after careful hearing of the case 
and a personal examination of the alleged insane person the said physicians 
shall certify on oath that the case is of recent or curable character, or that the 
said insane person is of a homicidal, suicidal, or incendiary disposition, or if 
from any other violent symptoms the said insane perscn Mould be dangerous to 
his own or her own life, or to the lives and propeity of the community in 
which he or she may live ; and if said physicians shall also certify to the 
name, age, nativity, residence, occupation, length of time in this State, apparent 
cause and class of insanity, duration of disease and present condition as nearly 
as can be ascertained by inquiry and examination ; and if the District Judge 
shall be satisfied that the facts in the examination establish the existence of 
insanity in the person of the accused, of a recent or curable nature, or of a 
homicidal, suicidal, or incendiary character, or from the violent symptoms the 
said insane person would be dargerous to his or her ov\ n life, or to the lives 
and propeity of others, to be at large, he shall direct the Sheriff or some 
suitable person to convey to the Capitol of the State and place such insane 
person in charge of the Secretary of the State, and shall transmit duplicate 
copies of complaint and commitment and physicians' certificates, which shall 
also be in form as furnished to the Judge, to the Secretary of the State. 



NEW HAMPSHIRE LAWS, 1889. 

Chapter 18. — Section 6. — Only Pauper Insane in County Asylums; 
Reports of County Superintendent. 

No person other than a pauper shall be admitted into any county asylum, 
and the Superintendent of every asylum or other place in this State where 
insane persons are confined, shall, within three days after the commitment of 
any person, notify the board of such confinement upon a blank furnished for 
that purpose ; and the said Superintendent shall at all times furnish such 
information regarding the insane in his charge as the State Board may request. 

1878. — Chapter 10. — Section 12. — Persons Dangerous, to be Committed 
to the Asylu?n. 

If any person is in such condition as to render it dangerous that he should 
be at large, the Judge of Probate, upon petition of any person and such notice 
to the Selectman of the town in which such insane person is, or to his guard- 
ian, or to any other person as he may order — which petition may be filed, 



LEGAL CARE OF THE INSANE. 597 

notice issued, and a hearing had in vacation or otherwise — may commit such 
insane person to the asylum. 

Sec. 18. — Certificate of two Physicians Required to Commit. 

No person shall be committed to the Asylum for the Insane, except by order 
of court or the Judge of Probate, without a certificate of two respectable 
physicians that such person is insane, given after a personal examination made 
within one week of committal ; and such certificate shall be accompanied by a 
certificate of the Judge of the Supreme Court, or of the Court of Probate, or 
Mayor, or Chairman, or Selectman, testifying to the truthfulness of the signa- 
tures of the signers. 

Sec. 25. — Superintendent may Furnish Stationary, Paper, and Transmit 
Letters to Trustees. 

It shall be the duty of the Superintendent to furnish stationary to any patient 
who may desire it, and transmit any letter such patient may address to the 
Board of Trustees to such member as said board shall have designated to 
receive such correspondence, and all such letters shall be promptly transmitted 
without interception. 



REVISED STATUTES OF NEW YORK, 1889. 

Chapter 446. — Article i. — Section i. — Commitment of the Insane. 

No person shall be committed to or confined as a patient in any insane 
asylum, public or private, or any institution, home, or retreat for the care and 
treatment of insane, except upon the certificate of two physicians, under oath, 
setting forth the insanity of such person. No person shall be held in confine- 
ment in any such asylum for more than five days, unless within that time such 
certificate be approved by a Judge or Justice of a court of record of the county 
or district in which the alleged lunatic resides ; and such Judge or Justice may 
institute inquiry and make proofs as to the fact of alleged lunacy before 
approving or disapproving such certificate ; and such Judge or Justice may in 
his discretion call a jury in each case to determine the question of lunacy. 

Sec. 2. — It shall not be lawful for any physician to certify to the insanity of 
any person for the purpose of securing their commitment, unless the physician 
be of reputable character and a graduate of some incorporated medical col- 
lege, a permanent resident of the State, and shall have been in actual practice 
of his profession for at least three years. And such qualification shall be 
certified to by a Judge of any court of record. No certificate of insanity 
shall be made except after the personal examination of the parties alleged to 
be insane, and according to the forms prescribed by the State Commissioner of 
Lunacy, and every such certificate shall bear a date not more than ten days 
prior to such commitment. 



59$ APPENDIX. 

Sec. 3. — It shall not be lawful for any physician to certify to the insanity of 
any person for the purpose of committing him to an asylum of which the said 
physician is either superintendent, proprietor, or officer, or a regular profes- 
sional attendant therein. 

Sec. 4. — Every Superintendent of the State Asylum, or public or private 
asylum, institution, home, or retreat for the care and treatment of insane, shall, 
within three days after the reception of any patient, make, or cause to be made, 
a description of such case entered, in a book exclusively set apart for that 
purpose, and shall also make entries from time to time mentioning state, 
bodily condition, and medical treatment of such patient, together with the 
forms of restraint employed during the time such patient remains under 
his care ; and in the event of discharge or death of such patient the Superin. 
tendent aforesaid shall state in his case book the circumstances pertaining 
thereto. 

Sec. 10. — Any overseer of the poor, constable, keeper of jail, or other persons 
who shall confine any lunatic in any seminary, or any other places than such 
as are herein certified, shall be deemed guilty of a misdemeanor, and on con- 
viction thereof shall be liable to a fine not exceeding $250, or imprisonment 
not exceeding one year, or both, at the discretion of the court before which the 
conviction shall be had. 

Sec. 33. — When any person is confined under the indictments of arson, 
murder, or attempt to murder, or highway robbery, or who has been acquitted 
thereof on the ground of insanity, and has been committed to some State 
lunatic hospital ***** shall be restored to his right 
mind, it shall be the duty of the Superintendent of such asylum to give 
notice thereof to the State Commissioner of Lunacy, who shall thereupon 
inquire into the truth of the fact, and if the same shall be proved to his 
satisfaction, he shall issue certificate, dated under his official hand and seal, 
to a Justice of the Supreme Court of the district in which such asylum is 
situated, who shall thereupon and upon such other facts as may be proven 
before him determine whether it is safe, legal, and right that such party in 
confinement, as aforesaid, shall be discharged. 

Sec. 24. — Discharge of Patients. 

The managers, upon the Superintendent's certificate of complete recovery, 
may discharge any patient, except when under a criminal charge, or liable to 
be remanded to prison, and they may discharge any patient admitted as " dan- 
gerous", or any patient sent to the asylum by the Superintendent or Overseers 
of the Poor, or by the (first) Judge of the county, upon the certificate of the 
Superintendent that he or she is harmless, and will probably continue so, and not 
likely to be improved by further treatment in the asylum, or when the asylum 
is full, upon a like certificate that he or she is manifestly incurable and can 



LEGAL CARE OF THE INSANE. 599 

probably be rendered comfortable at the poor-house, so that the preference may 
be given in the admisson of patients, to recent cases, or cases of insanity of 
not over one year's duration. They may discharge and deliver the patient, 
except when under criminal charge, as aforesaid, to his relatives or friends who 
will undertake, with good and approved sureties, for his peaceable behavior, 
safe custody, and comfortable maintenance without further public charge. 
And such sureties shall be approved by the county Judge of the county from 
which said patient was sent. * * * Upon the presentation of a 
certified copy thereof the managers may discharge such patient. 



LAWS OF NEW JERSEY, 1889. 

Chapter 168. — Superintendent or Warden to send a List of Patients 
Chargeable to the County. 

* * * It shall be the duty of the Superintendent or warden of the 
respective State asylums for the insane in this State, at which patients are 
supported at the expense of any county of this State, to make out under oath 
and send to the clerk of the Board of Chosen Freeholders of each and every 
county supporting patients at said asylums, at least three days before the 
meeting of the said Board of Freeholders, at which a quarterly bill of said 
asylum shall be presented, a regular and quarterly statement giving the names 
of all patients at said asylum at the expense of the county for which said state- 
ment is made, who have been at said asylum during the last preceding quarter, 
which statement shall also contain the dates of admission of the respective 
patients, the township from which they came, the days of discharge of any who 
have been discharged, the date of death of any who have died, and the dates 
between which they have been away on a visit or otherwise during the quarter. 

TRENTON ASYLUM, 1886. 

Section i. — Admission of Patients. 

* * * No person shall be admitted into the asylum as a patient 
except upon the order of some court or Judge authorized to send patients, with- 
out lodging with the Superintendent — first, a request under the hand of the 
person by whose direction he is sent, stating his age and place of nativity, if 
known, his Christian and surname, place of residence, occupation, and degree 
of relationship, and other circumstances of connection between him and the 
person requesting his admission; and, second, a certificate dated within a 
month, under oath, signed by two respectable physicians, of the fact of his being 
insane ; each person signing such request or certificate shall annex to his name 
his profession or occupation, and the township and county and State of his 
residence, unless these facts appear on the face of the documents. 



600 APPENDIX. 

Sec. 7. — Duties and Potuers of Physician. 

The Superintendent shall be the chief executive officer of the asylum ; he 
shall have the general superintendence of all the buildings, grounds, and farm, 
with their furniture, fixtures, stock, and the direction and control of all persons 
therein, subject to the law and regulations established by the managers ; he 
shall daily ascertain the condition of the patients, and prescribe their treat- 
ment in the manner prescribed in the By-laws; he shall appoint, with the 
approval of the managers, so many assistants and attendants as he may think 
proper and necessary for the economical and efficient performance of the busi- 
ness of the asylum, and prescribe their several duties and places, and fix, 
with the managers' approval, their compensation, and discharge any of 
them at his sole discretion ; but in every case of discharge he shall forthwith 
record the same with the reasons under the proper heading in one of the 
books of the asylum ; he shall also have the power to suspend until the next 
meeting (monthly) of the managers, for good and sufficient cause, any resident 
officer; but in such case he shall give written notice to the effect, with its cause 
and circumstances, to one of the managers, whose duty thereupon shall be to call 
a special meeting of the Board to provide for the exigency; he shall also from 
time to time give such orders and instructions as he may judge best calculated 
to insure good conduct, fidelity, and economy in every department of labor 
and expense; and he is authorized and enjoined to maintain salutary discipline 
among all who are employed by the institution, and to enforce strict compli- 
ance with such instructions and uniform obedience to all rules and regulations 
of the asylum ; he shall cause a full and fair account and record of all his doings, 
and of the entire business and operations of the institution, to be kept regularly 
from day to day in a book provided for that purpose, in the manner and to the 
extent prescribed in the By-laws ; and he shall see that all such' accounts and 
records are fully made up to the last day of December in the year, and that 
the principal facts and results, with reports thereon, be presented to the 
managers immediately thereafter. The assistant physician shall perform his 
duties and be subject to the responsibilities of the Superintendent in his sick- 
ness or absence. 

Sec. 36. — Discharge of Patients. 

* * The managers, upon the Superintendent's certificate of complete 
recovery, may discharge any patient except those under criminal charge or 
liable to be removed to prison ; and they may send back to the poor-house or 
township of the county from whence he came, any person admitted as danger- 
ous, who has been two years in the asylum, upon the Superintendent's 
certificate that he is harmless and will probably continue so, and not likely to 
be improved by further treatment in the asylum ; or when the asylum is full, 
upon the certificate that he is manifestly incurable and can probably be 



LEGAL CARE OF THE INSANE. 6oi 

rendered comfortable at the poor-house; they may also discharge and deliver 
any patient, except one under criminal charge as aforesaid, to his relatives or 
friends, who will undertake, with good and approved securities, for his 
peaceable behavior, safe custody, and comfortable maintenance without further 
public charge. 

Sec. 21. — Proceedings when Lunatics are Dangerous, if at large. 

That it shall be and may be lawful for any two Justices of the Peace of the 
county in which any lunatic, furious, mad, or dangerous, is permitted to go at 
large, shall be found, by warrant under their hands and seals, to direct the Over- 
seers or Overseer of the Poor of the city or township in which such lunatic or 
mad person may be found, to cause such person to be apprehended and kept 
safely locked up, and chained, if necessary, in some secure place within such 
city or township or within the county within which said city or township shall 
be situated, as such Justices shall by their warrant appoint, in case the legal 
settlement shall be in the city or township in the said county. 



NEW MEXICO, 1884. 

Section 1324. — Judge may Issue a Commission, zuhen. 

It shall be lawful for any District Judge in this Territory to issue a commis- 
sion, in term or vacation time, in the nature of a writ de lunatico inquirendo, 
to inquire into the lunacy or habitual drunkenness of any person within this 
Territory, or having real or personal estate therein. Such commission shall 
issue in the county wherein he last had his residence, or in which his prop- 
erty is situated, and shall be executed therein. 

Sec. 1327. — Order made to Court. 

It shall be the duty of the court at the time of granting any application as 
aforesaid, to make such order respecting notice of the execution of the com- 
mission to the party with respect to whom such commission shall be issued, or 
to some of his near relations or friends who are not concerned in the appli- 
cation, as the said court shall deem advisable. 

Sec. 1328. — Jury of Inquest. 

It shall be lawful for the commissioner or commissioners to direct an order 
to the Sheriff, requiring him to summon not less than nor more than twelve 
persons upon the inquest, as the circumstances to them may seem to require. 

Sec. 1329. — Inquisition; when held. 

If the court shall be of the opinion that the person with respect to whom 
proceedings are instituted has no estate, or not sufficient to justify the expense 
of a commission, and the proceedings under it, the Judge thereof, in person, 
shall hold said commission during the term of the court, and shall direct 
an inquest to be empannelled from the jurors attending said court, and which 
51 



602 APPENDIX. 

proceeding shall have like force and effect as an inquisition held by commis- 
sioners as aforesaid. 

Sec. 1354. — Jailor to give Notice. 

If any person arrested or imprisoned as aforesaid, in any civil action, shall 
appear to be of unsound mind, it shall be the duty of the jailor or keeper 
of the prison forthwith to give notice of the fact to two Justices of the Peace, 
who shall within five days attend at the prison, and, upon the oath or affirma- 
tion of such persons as they shall think fit to examine, proceed to inquire into 
the state of mind of such prisoner, and if they shall find him to be a lunatic 
as was alleged, they shall forthwith make a record of the fact, and certify the 
same to the Clerk of the District Court. 



CODE OF NORTH CAROLINA, 1883. 

SECTION 2249. — Superintendent ; Qualifications. 

* * * He shall be a skillful physician, educated to his profession, 
of good moral character, of prompt business habits, and of kindly disposition. 
He shall hold his office for six years from and after his appointment, unless 
sooner removed * * * for infidelity to his trust, gross immorality, or 
incompetency to discharge the duties of his office, fulfilled and declared, and 
the proof thereof recorded in the books. ****** 

Sec. 2250. — Assistant Physician. 

Each Board of Directors shall appoint one or more assistant physicians, and 
with the advice and consent of the Superintendent, prescribe his duties. Every 
assistant physician appointed shall hold his place for two years from and after 
the appointment, unless sooner removed by said Board for good cause, which 
shall be specified and recorded in their proceedings. 

Sec. 2253. — Superintendent to Control Officers. 

Such Superintendent shall exercise exclusive direction and control over all 
subordinate officers and employees engaged in the service and labors of his 
asylum, and he may discharge such as have been employed by himself or his 
predecessor, and shall report to the Board of Directors of the asylum the mis- 
conduct of all other subordinates. 

Sec 2256. — Proceedings to Obtain Admission to the Asylum. 

For admission into the asylum for the insane the following proceedings shall 
be had : Some respectable citizen residing in the county of the alleged insane 
person shall make before, and file with, the Justice of the Peace of the county, 
an affidavit. * * * Upon the bringing of the alleged insane person 
before the Justice of the Peace, or upon the return of the precept with 
the body of the insane person, the Justice shall cause to be associated with 
him one or more Justices of the said county, who together shall proceed to 



LEGAL CARE OF THE INSANE. 603 

examine into the condition of the mind of the alleged insane person, and shall 
take the testimony of at least one respectable physician, and such others as 
they may think proper. If any two of the Justices of the Peace shall be satis- 
fied that the person is insane, and some friend, as he may do, will not become 
bound with good security to restrain him from committing injuries, support, 
and take care of him until the cause for confinement shall cease, such Justices 
shall direct such, insane person to be removed to the proper asylum as a 
patient, and to that end they shall direct a warrant to the Sheriff or con- 
stable, and at the same time shall transmit to the proper Board of Directors, 
on examination of the witnesses, a statement of the facts as the said Justices 
shall deem pertinent to the subject matter. ****** 

Sec. 2259. — Action of the Superintendent in Doubtful Cases. 

Whenever an insane person shall be conveyed to any asylum, and the Sup- 
erintendent is in doubt as to the propriety of his admission, he may convene 
any three of the Board of Directors of his asylum, who shall constitute a Board 
for the purpose of examining and deciding that such person is a proper subject 
for admission, and if a majority of such Board shall decide so, such person 
shall be received into that asylum ; but that a like Board may at any time here- 
after deliver such insane person to any friend who may become bound with 
good security to maintain and take care of him in the same manner as he 
might have become bound under the surety of the Justice of the Peace. 

Sec. 2260. — Discharge of the Cured. Removal of the Incurables. 

Any three of the Board of Directors of any asylum, upon the certificate of 
the Superintendent * * * * * shall be a Board to dis- 
charge or remove from their asylum any person admitted as insane when such 
person has become or is found to be of sane mind; or when such person is 
incurable and in the opinion of the Superintendent his being at large will not be 
injurious to himself or dangerous to the community; or said Board may permit 
such person to go to the county of his settlement on probation, when in the 
opinion of the said Superintendent it will not be injurious to himself or dan- 
gerous to the community; and said Board may discharge or remove such person 
upon other sufficient cause appearing to them ; and whenever any such person 
admitted as indigent may be so discharged or removed, except as sane, it 
shall be the duty of the Sheriff of the county of his settlement to convey such 
person to his county at its expense; and any indigent person discharged as 
sane shall receive from such asylum a sum of money sufficient to pay his 
transportation to the county of his settlement, which sum shall be repaid by 
said county. 



604 APPENDIX. 

ACTS OF OHIO, 1888. 

Section i. — Application for Admission to the Asylum. 

Be it enacted by the General Assembly of the State of Ohio, that Section 705 
of the Revised Statutes of Ohio be amended so as to read as follows:— 

Probate Judge upon receiving certificate of medical witnesses * * * 
shall forthwith apply to the Superintendent of the hospital for the insane, 
situated in the district in which the patient resides; he shall at the same time 
transmit copies under his official seal of the certificate of the medical witnesses 
and of his findings in the case ; upon receiving application for certificate, the 
Superintendent shall immediately advise the Probate Judge whether the patient 
can be received, and if so at what time ; the Probate Judge, when advised that 
the patient will be received, shall forthwith issue his warrant to the Sheriff, 
commanding him forthwith to take charge of and convey such insane person 
to the asylum. *********** 

Sec. 709. — Discharge of Patients from the Insane Asylum. 
* * * On consent and advice of the Trustees, the Superintendent may 
discharge any patient from any asylum for the insane, when he deems such 
discharge proper and necessary ; provided, no patient with known homicidal 
or suicidal propensities shall be discharged without a bond in the sum of one 
thousand dollars, with two or more sureties, to be approved by the Probate 
Judge of the county of which the patient is an inhabitant, payable to any person 
who shall be injured in person or property by any insane act of such discharged 
person while at large, and such condition to save harmless by paying all dam- 
ages to such injured person as shall arise in consequence of such insane act, 
committed by such discharged person. 

Any incurable or harmless patients may be discharged to make room for 
acute cases from the same county ; and no patient with known homicidal or 
suicidal propensities shall be hereafter kept in any county infirmary or jail of the 
State, except temporarily, while awaiting the order for removal to the State 
asylum for the insane ; when in the opinion of the Superintendent the condition 
of the patient at the time of discharge is such as to justify such action he 
may permit such patient to go to his home or leave the institution unattended ; 
and if such patient is not financially able to bear his own expenses, the Super- 
intendent of the institution may furnish the patient a sufficient sum to pay his 
traveling expenses, and charge the same to the current expense fund of the 
institution; such sum shall in no one case exceed twenty dollars. * * * 

Sec. 704. — Certificates of Medical Attendants. 

At the time (unless for good cause the investigation is adjourned) the judge 
shall proceed to examine the witnesses in attendance; and if upon reading the 
testimony he is satisfied that the person so charged is insane, he shall cause a 
certificate to be made out by the medical witnesses in attendance. * * * 



LEGAL CARE OF THE INSANE. 605 

Sec. 710. — When Discharged as Cured. 

When a patient is discharged as cured, the Superintendent may furnish such 
patient with suitable clothing and a sum of money as he deems fit, not in any 
case exceeding twenty dollars. 

Sec. 712. — Proceedings 70/ien Person becomes again Insane. 

When a patient discharged from an asylum for the insane as cured again 
becomes insane, and a respectable physician files with the Judge of Probate of 
the county of which the insane person is an inhabitant an affidavit setting 
forth the fact of the recurrence of the disease and such other facts relating 
thereto as he deems proper, the Probate Judge shall forthwith transmit a copy 
of such affidavit, authenticated by his official seal, to the Superintendent of the 
proper asylum, and thereupon the same proceeding shall be had as provided 
in this chapter for persons found to be insane upon inque>t for that purpose. 

Sec. 715. — When Patient dies Relatives shall be notified. 

When a patient dies in any one of the asylums for the insane, the Superin- 
tendent thereof shall immediately notify relatives of such deceased patient, if 
known to him, and if not so known, he shall immediately notify the Probate 
Judge of the county from which such patient was sent, who shall forthwith 
cause a notice of his death to be printed in two of the leading papers pub- 
lished in the county. 

Sec. 736. — Qualifications for Admission. 

The asylum shall be open for admission of all persons over seven years, 
having a legal settlement in the County of Hamilton; but no person shall be 
entitled to admission unless he become insane after acquiring a legal settle- 
ment therein. 

Sec. 740. — Examination ; Physician's Certificate. 

At the time appointed (unless for good cause the investigation is adjourned) 
the Judge shall proceed to examine the witnesses in attendance, and if upon 
the hearing of the testimony such Judge is satisfied that the person so charged 
is insane, and is included in the class enumerated in this chapter, he shall 
cause a certificate to be made out by the physician, setting forth the name, age, 
residence of patient, with a concise history of the case, medical treatment 
pursued, supposed cause of disease, and such other information as is deemed 
useful. 

Sec. 741. — Patient shall be taken to the Asylum. 

The Probate Judge, upon receiving the certificate aforesaid, shall forthwith 
transmit a copy thereof, and his finding in the case, under his official seal, to 
some suitable person (giving the relatives of the insane person the preference), 
who shall immediately take charge of and convey such patient to the asylum, 
and return therefor to the Probate Judge a receipt of the Superintendent, to be 
filed with the other papers in the case. 



606 APPENDIX. 

LAWS OF OREGON, 1887. 

Section 3555. — Superintendent to make Pay-rolls of the Employees. 

At the end of each month the Superintendent shall cause a pay-roll to be 
made, on which the name of each person employed in or about the asylum, 
giving the capacity in which each is employed, the rate of salary or wages, and 
the amount due each ; upon receiving this pay-roll, duly receipted by the 
Superintendent and audited by the Board, the Secretary of the State shall 
draw his warrant on the Treasury in payment of the several amounts audited 
and allowed by the Board, and in favor of the person to whom the same is 
allowed, in a like manner as their warrants are drawn for the payment of claims 
against the State. 

Sec. — 3557. — Judge of the County to Hear and Determine Complaint of 
Insanity. 

The County Judge of any county in this State shall, upon application stated 
in writing, setting-forth that any person or persons, by reason of insanity or 
idiocy, is suffering from neglect, exposure, or otherwise is unsafe to be at large 
or is suffering under mental derangement, shall cause such person or persons 
to be brought before him at such time and place as he may direct ; and the said 
County Judge shall also cause to appear at the same time and place one or 
more competent physicians who shall proceed to examine the person or persons 
alleged to be insane or idiotic ; and if said physician or physicians, after 
careful examination, shall certify upon oath that such person or persons are 
insane or idiotic, as the case may be, then such Judge shall cause the said 
insane or idiotic person to be conveyed to and placed in the Insane Asylum of 
the State of Oregon. ****** 

Sec. 3553. — Superintendent as the Executive Officer. 

The Superintendent shall be the executive officer of the asylum under the 
regulations and by-laws of the Board of Trustees. He shall have control of 
the patients, prescribe their treatment, adopt necessary measures for their wel- 
fare, and discharge such as in his opinion have permanently recovered their 
reason, or such other patients as the best interests of the State and the institution 
require. He shall maintain discipline among the subordinate officers and 
employees, and enforce obedience to the laws, rules, and regulations adopted 
for the government of the institution; and is empowered to discharge any 
employee or attendant for violation of the laws or rules of the asylum, 
and submit the same to the Board of Trustees immediately for their ap- 
proval. He shall remit to the Board of Trustees a report of the amount, 
kind, and quantity of furniture and household furnishing goods, provisions, 
fuel, forage, cloth, and other material required for six months ending 
on the first day of June and December of each year, and the Trustees 
shall then advertise, when practicable, for four successive weeks, for contracts 



LEGAL CARE OF THE INSANE. 6oj 

fcr furnishing said supplies, or so much thereof as they deem necessary. 
* * * Necessary expenditures other than for provisions, fuel, forage, 
clothing, and furniture, and household furnishing goods may be made by the 
Superintendent subject to the approval of the Board. * * * * 

Sec. 3554. — Superintendent to keep Accurate Accounts and make Monthly 
Reports. 

The Superintendent shall cause accurate and careful accounts to be kept of 
the daily expenditures of all classes of stores and property placed in his charge, 
and shall at the end of each month submit the same to the Trustees for their 
inspection, and on each daily report shall be shown the number of persons 
having lodging in the asylum, whether as officer, employee, or patient. * * 



LAWS OF PENNSYLVANIA, 1873. 

Sec. I. — On what Evidence Insane Persons may be placed in an Asylum. 

Insane persons may be placed in a hospital for the insane by their legal 
guardians, * * * or by their relatives or friends in case they 
have no guardians, but not without the certificate of two or more reputable 
physicians under a personal examination made within one week of the date 
thereof; and this certificate to be duly acknowledged and sworn to or 
affirmed before some Magistrate or judicial officer, who shall certify to the 
genuineness of the signatures and to the responsibility of the signers. 

Sec. 13. — Philadelphia State Lunatic Asylum Physician. 

* * * The Trustees shall have charge of the general interests of the 
institution; they shall appoint a Superintendent who shall be a skillful physi- 
cian, subject to removal or re-election no oftener than the period of ten years, 
except by infidelity to the trust reposed in him, or for incompetency ; said 
physician shall also reside in the asylum, and shall be a married man, and his 
family shall reside with him. ******** 

Sec. 14. — Powers of the Superintending Physician. 

The superintending physician shall appoint and exercise entire control over 
subordinate officers and assistants in the institution, and shall have entire dis- 
cretion of the duties of the same. 



LAWS OF PENNSYLVANIA, 1883. 

Section 19. — Time within which Certificate must be made. 

The certificate above provided for shall have been made out within one 
week of the examination of the patient, and within two weeks of the time of 
the admission of the patient, and shall be duly sworn to or affirmed before a 
Judge or Magistrate of this Commonwealth, and of the county where such 



608 APPENDIX. 

person has been examined, who shall certify to the genuineness of the signa- 
tures, and to standing and good repute of all the signers. And any person 
falsely certifying as aforesaid shall be guilty of misdemeanor and also liable. 

Sec. 23. — Duty of Medical Attendant. 

* * * The regular medical attendant of the house shall, within twenty- 
four hours after the reception of any patient, examine such patient and reduce 
to writing the results of such an examination, and enter the same upon the 
book to be kept for the purpose, with the opinion formed from such exam- 
ination and from the documents received with the patient. 

Sec. 24. — When Detention unnecessary, Notice to be given. 

In case the said medical attendant is of the opinion that detention is not 
necessary for the benefit of the patient, he shall notify the person or persons at 
whose instance the patient is detained, and unless such a person shall without 
a delay not exceeding seven days exhibit satisfactory proof of such necessity, 
the patient shall be discharged from the house and restored to his family or 
friends. 

Sec. 25. — Interviews Allowed. 

At the time of such examination the medical attendant shall himself cause the 
patient strictly to understand, if he or she is capable of doing so, that if he or she 
desires to see or otherwise communicate with any person or persons, means 
will be provided for such interview or communication, and said attendant shall 
see that the proper means are taken to communicate this fact to the person or 
persons indicated by the patient; or any proper person or persons not exceed- 
ing two shall be permitted to have a full unrestrained interview with the patient. 

Sec. 26. — Reports to be made by the Medical Attendant. 

The statement furnished at the time of the reception of the patient (and of 
the examination of the patient by the medical attendant of the house) shall be 
forwarded by mail to the address of the Committee on Lunacy within seven 
days from the time of the reception of the patient, which shall by them be 
entered in a book which shall be kept for the purpose, and at least once in six 
months there shall be repoits made by the medical attendant of the house on 
the condition of the patient, together with such other matters relative to the 
case as the said committee may require; and at the same time such report 
shall be made by request of the secretary of the Committee on Lunacy. 

Sec. 28. — Materials for Correspondence, etc. 

All persons detained as insane shall be furnished with materials and reason- 
able opportunity, under the discretion of the Superintendant or manager, for 
communicating under seal, without the building, and such communication shall 
be stamped and mailed; they shall have the unrestrained privilege of address- 
ing communications, if they so desire, not oftener than once a month, to any 
member of the Committee on Lunacy. 



LEGAL CARE OF THE INSANE. 609 

Sec. 31. — Persons Restored to Reason to be Forthwith Discharged. 

All persons that have been detained as insane (other than criminal insane 
duly convicted and sentenced by a court), shall, as soon as they are restored to 
reason and are competent to act for themselves, in the opinion of the medical 
attendant of the house, be forthwith discharged ; and any person so detained 
shall at all times be entitled to a writ of habeas corpus for the determination 
of this question. * * * * In case the discharged patient be 
in indigent circumstances, such person shall be furnished with necessary rai- 
ment and with funds sufficient for sustenance and travel to his home, to be 
charged to the county from which such patient was committed. 

Sec. 32. — Committee to be Notified of Discharges. 

The Committee on Lunacy shall be notified of all discharges within seven 
days thereafter, and a record of same shall be kept by the committee. 

Sec. 36.— Postal Privileges of the Patients. 
* * * a That it shall be unlawful and be deemed a misdemeanor in 
law, punishable by fine not exceeding one hundred dollars, for any Superinten- 
dent, officer, physician, or other employee of any insane asylum, to intercept, 
delay, or interfere with in any manner whatsoever, the transmission of any letter 
or other written communication addressed by an inmate of any insane asylum 
to his or her counsel residing in the county in which the home of the patient 
is, or the State or county in which the asylum is located," is hereby amended 
so that the same shall extend to superintendents, officers, servants, or other 
employees of all hospitals, houses, or places which are subject to the provision 
of this act. 

STATUTES OF RHODE ISLAND, MAY, 1884— 
JANUARY, 1885. 

Chapter 479. — Apportionment of Insane Paupers at the Butler Hospital 
or other Curative Hospitals. 

Whenever it shall appear by the written certificate of two practicing physi- 
cians of good standing that any pauper within the State is insane, and may be 
benefited by curative treatment, the Agent of State Charities and Corporations, 
with the written consent of the Governor, may place such insane pauper in 
the Butler Hospital for the Insane ; but in case such pauper cannot be received 
in the said hospital, then at some public curative hospital for the insane within 
the State. 

PUBLIC STATUTES OF RHODE ISLAND, 1882. 
Chapter 74. — Section i. — Whenever complaint in writing and under oath 
shall be made to any trial justice or clerk of a justice court, that any person 
within the county is a lunatic, or so furiously mad as to render it dangerous to 
52 



6lO APPENDIX. 

the place or safety of the good people of the State, for him to be at large and that 
such person is at large, such trial justice or clerk shall issue his warrant, under 
his hand and seal and returnable forthwith, directed to the deputy sheriffs, town 
sergeants, or constables requiring the officer charged therewith to apprehend 
such person, and convey him with such warrant before such or some other 
justice court fur examination relative to such complaint. 

Sec. 2. — Examination and Proceedings on Return of the Warrant and 
Commitment of the Mad Person. 

If the court on such examination shall adjudge such complaint to be true, 
it shall, unless a recognizance satisfactory to said court be then given before it, 
that said person shall not be permitted to go at large until restored to sound- 
ness of mind, commit such person by warrant under its hand and seal to the 
Butler Hospital for the Insane, or to the State Hospital for the Insane, there to 
be detained until in the judgment of some Justice of the court of the county 
in which he may be detained, he shall, upon inspection and examination, be 
declared to be restored to soundness of mind, or to be no longer under the 
necessity of restraint, or until recognizance as aforesaid, satisfactory to such 
court, shall be given. 

Sec. io. — When a Person committed may be Discharged though not Cured 

Any person committed to any such institution under the previous proceed- 
ings of the Fourth Section may, although not restored to sanity, be discharged 
therefrom upon the written recommendation of the Trustees and Superintendent 
thereof, or an order of any Justice of the Supreme Court, to be made in his 
discretion. 

Sec. ii. — Commitment of Lunatics. 

Insane persons may be removed to and placed in the said Butler Hospital 
or State Asylum for the Insane, if they can be there received, and if not, in any 
other curative hospital for the insane of good repute in this State. * * * But 
the Superintendent of said hospital shall not receive any person into his 
custody in such case without the certificate from two practicing physicians of 
good standing, known to him as such, that such person is insane. 

Sec. 1 2. — Powers of Superintendent to Receive and Detain Lunatics. 

Any person committed to the charge of any of the said institutions for the 
insane as aforesaid, in either of the modes herein described, may lawfully be 
received and detained in said institution by the Superintendent thereof, and by 
his keeper and servants, until discharged by any one of the modes herein pro- 
vided; and no Superintendent, his keepers or servants, nor the Trustees or 
agents of same, shall be liable, civilly or criminally, for receiving or detaining 
such person so committed or detained. 

Sec. 14. — Superintendent may discharge ; when. 

The Superintendent of such institution for the insane within the State may, 



LEGAL CARE OF THE INSANE. 6 1 I 

on the application of any relative or friend, with the proper approval in writing 
of the visiting committee or Trustees, discharge from such institution any patient 
not committed by process of law. 

Sec. 30. — To visit Insane Persons. 

The State Commission, or either of the members thereof, shall from time to 
time in their discretion visit every institution or place wherein any person insane 
or alleged to be insane is restrained of his liberty, and alone or attended, as they 
shall elect, examine into the condition and complaint of any one so confined. 

Sec. 31. — Duty of Persons in Charge of Insane Persons. 

The Superintendents, officers, keepers, and assistants, and other persons in 
charge wherever any insane person is confined, are forbidden and enjoined 
from in any way or manner interfering, hindering, or preventing any person 
so confined from communicating at all times, in manner as aforesaid, with 
said commission, except under consultation, and with the full consent in 
writing of the commission. And every such Superintendent, officer, keeper, 
and assistant, or other person, shall afford to every person under his charge, 
with the exception of the aforementioned, every facility for making such 
communications, according to the true intent and meaning thereof, and shall 
forward such communication to the said commission without delay. 



LAWS OF SOUTH CAROLINA, 1884. 

Act 508. — Section i. — Certificate of Physicians. 

* * Physicians examining summoned persons alleged to be insane for* 
admission to a lunatic asylum shall certify under oath that they are regis- 
tered in accordance with the State law, that they have examined the persons 
separately, and that they are not related by blood or marriage to any of the 
persons; they shall also certify under oath that to the best of their medical 
knowledge the persons they recommend for admission to the lunatic asylum 
are epileptics, idiots, or lunatics, incurable at home, and that they are violent 
or dangerous. 

Sec. 2. — Idiots, Epileptics, etc., not to be sent unless violent. 

Physicians giving certificates recommending commitment to the asylum of 
a person who is simply idiotic, epileptic, physically infirm or mentally imbecile, 
unless such person is violent or dangerous, shall be deemed guilty of a mis- 
demeanor, and upon conviction thereof shall be fined by the District Court. 

LAWS OF 18S2. 
Act 121. — Section I. — Terms and Conditions upon which Patients may 
be Admitted into the Asylum. 
* * The Superintendent and Regents of the State Lunatic Asylum 



6l2 APPENDIX. 

shall not receive into said institution any beneficiary patient, unless the order 
consigning such person to the asylum is accompanied by report from the 
County Commissioners of the county from which such person is sent, certifying 
that they have carefully investigated the circumstances and conditions of such 
person, his or her family, parent, or guardian, and that such person is a proper 
subject for the beneficiary care and to what extent. 



SOUTH CAROLINA LAWS, 1881-2. 

Chapter 646. — Section i. — Hotv Lunatics are to be Sent to the Asylum. 

* * * All officers now authorized by law to send insane persons to the 
lunatic asylum shall, before sending such insane person to the asylum, notify 
the chairman of the Board of County Commissioners, or one of such Board, that 
such person should be sent to the lunatic asylum, having first had such lunatic, 
if of a dangerous or violent character, so secured as not to do any damage or 
injury. * * * 

Sec. 1586. — How to be Admitted to the Asylum. 

It shall be the duty of the Regency to admit as subjects of the institution all 
idiots, lunatics, and epileptics, under the statutes of this State and subject to 
the following conditions ; that is to say: * * * (3) all persons who shall 
be declared lunatics, idiots, or epileptics. After due examination by one 
trial Justice and two licensed practicing physicians of the State, where the 
subject is a pauper, the admission shall be at the request of the County Com- 
missioners wherein such pauper has a legal settlement; otherwise the admis- 
sion shall be at the request of the husband or wife, or where there is no hus- 
band or wife, of the next of kin of the idiot, lunatic, or epileptic. 

Sec. 1588. — Judges may Direct Inquisition. 

Whenever a Judge of Probate or a Judge of the Circuit Court shall direct 
an order to any trial Justice to inquire as to the idiocy, lunacy, or epilepsy of 
any person, or when information on oath shall be given to any trial Justice that 
a person is an idiot, lunatic, or epileptic, and is chargeable for his support on the 
county, it shall be the duty of said trial Justice forthwith to call to his assist- 
ance two licensed practicing physicians, and examine such person as to evi- 
dence of his or her idiocy, lunacy, or epilepsy, and if after full examination 
they shall find such person an idiot, lunatic, or epileptic, they shall certify to 
said Judge or Board of County Commissioners whether in their opinion such 
person is curable or incurable, and whether his enlargement would be harm- 
less or dangerous or annoying to the community; and thereupon the Judge or 
Board of County Commissioners in its discretion may make an order that the 
said person shall be sent to the lunatic asylum. 



LEGAL CARE OF THE INSANE. 613 

Sec. 1594. — Discharge of Lunatics. 

Whenever any lunatic or epileptic shall have recovered, it shall be the duty 
of the Regents to discharge him from the asylum. 

Sec. 1596. — Ill-treatment of Patients by Employees. 

It shall be the duty of the Regents to remove from office and cause to be 
indicted any person employed in the said institutions who shall assault any 
idiot, lunatic, or epileptic in their care, with greater violence than may be 
necessary for his or her restraint, government, or care. 



CODE OF TENNESSEE, 1884. 

Article II. — Section 2027. — Qualifications of Superintendent. 

The Superintendent of the hospital shall be appointed by the Board of 
Trustees, and shall be a skillful physician, of unblemished moral character, of 
enlightened and thorough professional education, of prompt business habits 
and of humane and kind disposition. 

Sec. 2028. — Residence, etc. 

He shall be a married man, and with his family shall reside constantly in the 
institution. 

Sec. 2029. — Term of Office. 

He shall hold his office for eight years, but may be removed by the Board of 
Trustees for infidelity to his trust or incompetency fully shown and declared. 

Sec. 2030. — Pozvers over Officers. 

He shall exercise entire control over all subordinate officers and assistants 
in the hospital, and shall have entire direction of the duties of same, he him- 
self being accountable to the Board of Trustees for their good character and 
fidelity in the discharge of their duties. 

Sec. 2036. — Duties. 

It shall be the duty of the Superintendent, under the orders of the Board of 
Trustees — First, to exercise a general superintendency over all matters relating 
to the hospital. Second, to visit the patients therein at least twice a week, or 
oftener if necessary. Third, to call meetings of extraordinary importance of the 
Board whenever he may deem it necessary. Fourth, to report to the Trustees 
immediately before each General Assembly : first, the number of patients ad- 
mitted into the asylum; second, date of admission of each patient; third, the 
degree and kind of insanity with which each patient is afflicted; fourth, length 
of time each person was supposed to have been affected before admission; fifth, 
the profession, occupation, age, and habits of each patient, and whether mar- 
ried or single ; sixth, the names of those discharged, and the condition of each 
when discharged ; seventh, and such other particulars as he may deem neces- 
sary to further action and legislation thereon. 



6 14 APPENDIX. 

Sec. 2037. — In Reference to Removal of Patients. 

The Superintendent, by authority of the resident Board of Trustees or a 
majority of them, shall have power to require the removal of any patient, pay- 
ing or non-paying, whenever in their opinion it is advisable to do so. 



TITLE 7.-REVISED STATUTES OF TEXAS, 1879. 

Article 67. — Board of Managers. 

The general control and management and direction of the affairs of the 
State Asylum shall be vested in the Board of Managers, to be styled the 
" Board of Managers of the Lunatic Asylum." 

Art. 73. — Monthly Inspection. 

One or more of the Managers shall visit the asylum and inspect the same at 
least once every month. 

Art. 75. — Superintendent Provided For. 

The Governor of this State shall appoint, by and with the advice and con- 
sent of the Senate, a Superintendent of the lunatic asylum, who shall, unless 
sooner removed, hold his office for a term of two years, and, in the case of 
a vacancy in said office, the appointment shall be only for the expiring term, 
and the term of such officer shall, in any event, expire with the term of the 
Governor making the appointment. 

Art. 76. — Qualification of the Superintendent. 

The Superintendent shall be a married man, and also of experience in the 
treatment of insanity. He shall reside in the hospital with his family, and 
shall devote his whole time exclusively to the duties of his office. 

ART. 80. — Powers and Duties of the Superintendent. 

The Superintendent shall be the chief executive, medical, and disbursing 
officer of the institution, and subject to the by-laws, but shal have general care 
and control over everything connected therewith. He shall attend to the 
enforcement of the laws of the State relating to the asylum, and by-laws of the 
institution, and shall take care that all employees connected therewith dili- 
gently and faithfully perform duties assigned to them. 

Art. 81. — The Superintendent shall also, with the consent of the Board 
of Managers, employ such officers, attendants, and other persons as may be 
required for the service of the institution, and with like consent may discharge 
them at pleasure. He shall also receive and discharge patients, superintend 
repairs and improvements, and take care that all moneys entrusted to him are 
judiciously and economically expended. 

Art. 82. — The Superintendent shall keep also an accurate and detailed 
account of all moneys received and expended by him, certifying the source 
from which such moneys were received, and to which and on what account to 



LEGAL CARE OF THE INSANE. 615 

be used; and on the 1st day of July of each year he shall report the same 
under oath to the Governor. 

Art. 83 — The Superintendent shall also keep and register patients re- 
ceived into the asylum and discharged therefrom, together with a full record 
of all the operations of the institution, and on the 1st day of November of 
each year he shall report such operations in full to the Governor, accompanied 
with such suggestions and recommendations concerning the management and 
operations of the asylum as may be deemed important. 

Art. 84. — Annual Inventory. 

On the 1st day of November of each year the Superintendent shall cause 
inventory of all the personal property belonging to the asylum to be prepared, 
in which inventory an estimated value shall be set beside each article, and 
shall submit the same to the Board of Managers. 

Art. 92. — Before any person can be received as a patient * * 

**■*•*■*** the parent or legal guardian of such 
person, or in the case he has no parent or guardian, then some one 
relative or other person interested in him must present a written request to the 
Superintendent for his admission, setting forth the name, age, residence of the 
lunatic, together with such particulars as may be required by the Superinten- 
dent or the by-laws of the institution ; which written request must be under 
oath of the party representing it, and be accompanied with an affidavit of the 
physician certifying to the insanity, that he has made a careful examination of 
the person for whom admission is applied for, and verily believes him to be 
insane. 

Art. 93. — County Judge must Certify. 

The application referred to in the preceding article must also be accom- 
panied by the certificate of the County Judge of the county where the lunatic 
resides, that the physician certifying to the insanity of the person under charge 
is a respectable physician in regular practice, which certificate of the County 
Judge must be attested by the seal of the county court of his county. 

Art. 99. — Discharge of Patients. 

Any patient, except such as are charged with or convicted of some offense 
and have been adjudged insane in accordance with the provisions of the code 
of criminal procedure, may be discharged from the asylum at any time upon 
the recommendation of the Superintendent, approved by the Board of Mana- 
gers. Any patient coming within the above exception can only be discharged 
by order of the court by which he was committed. 

Art. 100. — No patient shall be discharged without suitable clothing and 
sufficient money to pay his expenses home; and when a patient is discharged 
by order of the court he shall be provided with a suitable guard and conveyed 
to his friends, or to the county from which he was sent. 



6l6 APPENDIX. 

Art. 106. — Apprehension of Lunatics. 

If information written under oath be given to any County Judge, that any 
person in his county is a lunatic or non compos mentis, and that the welfare 
of himself or of others requires that he be placed under restraint, and said 
County Judge shall believe such information to be true, he shall forthwith 
issue his warrant for the apprehension of such person, and shall fix a day for 
the hearing and determination of the matter. 

Art. 1 20. — Suitable Clothing to be Provided. 

Before sending any patient to the asylum the County Judge shall take care 
that the patient is provided with two full suits of substantial summer clothing, 
and one full suit of substantial winter clothing. 



LAWS OF UTAH, I88O. 

Chapter 31. — Section 13. — Qualifications of the Medical Superintendent 
and his Duties. 

The Medical Superintendent shall be well educated, an experienced physi- 
cian, and a regular graduate in medicine, and shall have practiced at least five 
years from the date of his diploma. He shall have the general superintend- 
ence of the buildings, grounds, and property thereof, subject to the laws and 
regulations of the Directors. He shall have control of the patients, prescribe 
their treatment, adopt sanitary measures for their welfare, and discharge such 
as in his opinion have permanently recovered their reason. He shall appoint, 
with the approval of the Directors, as many attendants as may be necessary 
for the efficient and economic care and management of the asylum, and, with 
the consent of the Board of Directors, fix their compensation and discharge 
any of them. He shall prescribe the duties of the subordinate officers, main- 
tain discipline among them, and enforce obedience to the laws, rules, and 
regulations adopted for the government of the institution. He shall estimate 
quarterly, in advance, the probable expenses of the asylum, and submit the 
same to the Board of Directors at their regular meeting preceding the com- 
mencement of such quarter, for their approval. * * * * The 
Medical Superintendent shall cause to be kept full and accurate accounts and 
records of his official transactions from day to day, in books provided for that 
purpose, in the mode prescribed in the by-laws. He shall see that his accounts 
are fully made up to the thirty-first of December in each year, and shall sub- 
mit his annual report to the Board of Directors immediately. He shall visit 
the asylum every day in the year, unless he obtain leave of absence from the 
president of the Board of Directors, in which event the assistant physician 
shall discharge his duties. * * * * 



LEGAL CARE OF THE INSANE. 6\J 

Sec. 1 6. — Judge of Probafe may, if found necessary, direct that Insane 
Persons be placed in an Insane Asylum. 

The Probate Judge of any county in this Territory shall, upon application 
under oath, setting forth that a person, by reason of insanity, is dangerous to 
be at large, cause such person to be brought before him, and he shall summon 
to appear, at the same time and place, two or more witnesses who well knew 
the accused during the time of alleged insanity, who shall testify, under oath, 
as to the conversation, manners, and general talk upon which charge insanity 
is based, and shall also cause to appear before him, at the same time and place, 
two practicing physicians in medicine, before whom the Judge shall examine 
the ch arged ; and if, after a careful hearing of the case and a personal examina- 
tion of the alleged insane person, the said physicians shall certify, on oath, 
that the person is insane, and the case is of recent or curable character, or that 
the insane person is of homicidal, suicidal, or incendiary disposition, and that 
from any other violent symptoms the said insane person would be dangerous 
to his or her own life, or to the lives or property of the community in which 
he or she may live, and the said physicians shall also certify to the name, age, 
nativity, residence, occupation, length of time in the Territory, State, or 
county last from, previous habits, premonitory symptoms, apparent cause, and 
class of insanity, duration of the disease, and present condition, as nearly as 
may be ascertained by inquiry and examination; and if the Judge shall be 
satisfied that the facts revealed in the examination establish the insanity of 
the person accused, and that it is of a recent or curable nature, or of homi- 
cidal, suicidal, or incendiary character, or that from the violence of the symp- 
toms the said insane person would be dangerous to his or her own life, or to the 
lives or property of others, if at large, he shall direct a Sheriff of the county, 
or some suitable person, to convey to and place in charge of the officers of the 
Territorial Insane Asylum such person, and shall transmit a copy of the com- 
plaint and commitment, and physicians' certificate, which shall also be in the 
form furnished by the Medical Superintendent of said asylum. * * * 



VERMONT, 1884. 

Act No. 52. — Section i. — It is hereby enacted by the General Assembly 
of the State of Vermont, that section 2898 of the Revised Laws is hereby 
amended so that it will read as follows : — 

The Supervisors shall visit the Vermont Hospital for the Insane as often as 
occasion requires, and one member as often as once a month ; and also any 
other place where insane penons are confined in the State, at their discretion ; 
shall examine into the condition of the said asylum, and such other places 
where insane persons are confined, the management and treatment of the 



6l8 APPENDIX. 

patients therein, their physical and mental condition, and medical treatment ; 
form a careful opinion of the patients, apart from the officers and keepers, and 
investigate the cases that in their judgment require special investigation, and 
particularly ascertain whether persons are confined in such asylum or other 
places who ought to be discharged. They shall have the general supervision 
of the insane of the State not in confinement, so far as it concerns their physi- 
cal and mental condition, their care, management, and medical treatment ; and 
also those who are discharged from such asylum or place of confinement by 
authority under Section IV of the act approved November 28, 1882, and shall 
make such order therein as such case requires. 

REVISED STATUTES, I88O. 

Chapter 139.— Section 2897. — Supervisors. 

The General Assembly shall elect biennially three Supervisors of Insane, 
who shall hold their office for two years commencing on the first day of the 
next December; and the Governor may fill vacancies of the Board during the 
term. Two of said supervisors shall be physicians, and none of them shall be 
a trustee, superintendent, employee, or other officer of an insane asylum in the 
State. 

Sec. 2900. — Powers of the Supervisors. 

The Supervisors may administer oaths, summon witnesses before them in 
any case under their investigation, and discharge by their order in writing any 
person confined as a patient in any asylum for the insane whom they find on 
investigation to be wrongfully confined, or whom they find so far sane as to 
warrant discharge. But convicts sent to an asylum from the State Prison or 
House of Correction, who are found sane before the expiration of their 
sentence, shall not be discharged, but the Supervisor shall order their return to 
the Prison or House of Correction. In no case shall the Supervisor order the 
discharge of a patient without giving the Superintendent of the asylum an 
opportunity to be heard. 

Sec. 2905. — Fine for not Discharging Patient after Recovery. 

If a trustee, superintendent, employee, or other officer of any asylum for the 
insane wilfully and knowingly neglects or refuses to discharge a patient after 
such patient has become sane, or after the Supervisors have ordered his dis- 
charge, such trustee, superintendent, employee or other officer shall be fined 
not more than five hundred dollars. 

Sec. 2906. — Physician" 1 s Certificate Required. 

No person, except as hereinafter provided, shall be admitted or detained in 
an insane asylum as a patient or inmate, except upon the certificate of such 
person's insanity made by two physicians of unquestioned integrity and skill, 
residing in the probate district in which such insane person resides, or if such 



LEGAL CARE OF THE INSANE. 619 

insane person is not a resident of the State in the probate district in which the 
asylum is situated; or if such insane person is a convict in the State Prison 
or House of Correction, such physicians may be residents of the probate dis- 
trict in which such place of confinement is situated. 

Sec. 2907. — Certificate, When to be made. 

Such certificate shall be made not more than ten days previous to the 
admission of such insane person, and, with the certificate of the Judge of 
Probate of the district in which the physicians reside that such physicians are 
of unquestioned integrity and skill in their profession, shall be presented to 
the proper officer at the time such insane person is presented for admission. 

Sec. 2908. — Physicians to Certify upon Examination. 

The certificate of the physician shall be given only after a careful examina- 
tion of the supposed insane person, made not more than five days previous to 
the giving of the certificate ; and the physician who signs the certificate with- 
out making such previous examination shall, if the person is admitted to any 
asylum under the certificate, be fined not less than fifty dollars and not more 
than one hundred dollars. 



CODE OF VIRGINIA, 1887. 

Section 1668. — Annual Reports. 

The Board of each asylum shall annually before the first day of November 
report to the Governor, for the information of the General Assembly, the condi- 
tion of the asylum, and an account of all sums received and disbursed, with a 
list of the patients designated by name or otherwise in the asylum during the 
preceding year, showing their age and sex, place of residence, and civil con- 
dition, deaths, and discharges, and condition when discharged, and any statistics 
and remarks as to the management of insane and the subject of insanity which 
in their judgment may be useful. 

Sec. 1669. — -^ n y Justice who suspects any person in his county or corpora- 
tion to be a lunatic, shall issue his warrant ordering such person to be brought 
before him. He and two other Justices shall inquire whether such person be a 
lunatic, and for that purpose summon his physician (if any), and any other 
witnesses. * * * 

Sec. 1670. — If the Justices decide that the person is a lunatic and ought to 
be confined in an asylum, unless some person (to whom the Justices in their 
discretion may deliver such lunatic) will give bond with sufficient security to 
be approved by them, payable to the Commonwealth, with condition to restrain 
and take proper care of such lunatic until the cause of his confinement shall 
cease, or the lunatic is delivered to the Sheriff of the county or corporation, to 
be proceeded with according to law, the said Justices shall order him to be 



620 APPENDIX. 

removed to the nearest asylum on receipt of notice of there being room therein, 
and if not, to either of the others. 

Sec. 1673. — The Superintendent of the asylum, when such vacancy exists, 
is authorized, when practicable, to send a guard for the lunatic, or empower any 
person of responsibility and character to guard and conduct him to the asylum, 
and furnish the person so appointed with a certificate of his appointment ; or, 
where neither of such arrangements are practicable, the Sheriff shall conduct 
such lunatic to the asylum. ********* 

Sec. 1674. — Examination and Admission of Lunatics. 

When such patient arrives at the asylum the Superintendent or his attendants 
shall examine him, and if they concur in opinion with the Justices, shall receive 
and register him as a patient. 

Sec. 1688. — Discharge of other Restored Lunatics. 

When any other person confined in an asylum or jail as a lunatic shall be 
restored to sanity, the Superintendent or the Court, as the case may be, shall 
discharge him and give him a certificate thereof. 



CODE OF WASHINGTON, 1881. 

Section 2251. — Appointment and Qualifications of Superintendent. 

The Superintendent shall be a skillful practicing physician, and shall reside 
upon the hospital grounds ; he shall be at his office for such time as the Trustees 
may deem wise, and for the efficiency and economy of the institution, he shall 
have entire control of the medical, moral, and dietetic treatment of the patients, 
and, so far as is not inconsistent with the by-laws and regulations of the 
hospital, of all other internal government and economy of the institution ; and 
he shall in such manner, and under such restrictions, and for such terms of time 
as the by-laws may prescribe, appoint all subordinate employees, and shall 
have entire direction of them in their duties. 

Sec. 2260. — No Person Laboring under Contagious Disease Admitted. 

No person laboring under any contagious or infectious disease shall be 
admitted in said hospital as a patient. 

Sec. 2264. — When and how Patients may be Discharged. 

Any patient may be discharged from the hospital, when in the judgment of 
the Superintendent it may be expedient. Whenever a patient not cured, or 
any indigent patient shall be ordered discharged, the Superintendent shall im- 
mediately send notice thereof to the Probate Judge of the county in which said 
patient resided, and if in the judgment of the Superintendent such patient so 
ordered to be discharged is in fit condition to be sent to his or her county by 
any person, the Superintendent may return the patient to the county, from 
whence he or she came, if indigent, at the expense of said county; but if such 



LEGAL CARE OF THE INSANE. 621 

patient so ordered to be discharged from said hospital and care, without 
endangering the health of such patient, is through or by any reason unfit to 
be sent alone to the county from which he or she was committed to said 
hospital, the Superintendent shall so certify to the Probate Judge of said county, 
who shall immediately upon receipt of the notice issue his warrant to the 
Sheriff, commanding him to remove the patient and return him or her to the 
county from whence he or she came. If, within thirty days after the notice, 
the patient be not removed, the Superintendent, if he thinks necessary, may 
return the patient to the county from which he or she came, at the expense of 
the county; provided, that if any such patient is not in a condition to either 
go or be removed to said county, he or she may, for the time being, be retained 
in said hospital at the expense of the county from which he or she was so 
committed. 

Sec. 2267. — The Sziperin ten dent shall Ascertain History of each Patient. 

It shall be the duty of the Superintendent to ascertain, by diligent inquiry 
and correspondence, the history of each and every patient admitted to the 
hospital, and whether such patients, or their friends or families, if there be any, 
are able to defray the expenses of his or her care, and report the facts to the 
board of trustees, who shall use efficient means for the collection of all sums 
due the institution, from those who are able to pay for such care. 

Sec. 2273. — Correspondence of Patients free frotn Censorship. 

There shall be no censorship exercised over the correspondence of inmates 
of insane asylums, except as to the letters to them directed ; but their other post- 
office rights shall be as free and unrestrained as are those of any other resident 
or citizen of this territory, and be under the protection of the same postal laws; 
and every inmate shall be allowed to write one letter per week to any person 
he or she may choose. And it is hereby made the duty of the Superintendent 
to furnish each and every inmate of each and every insane asylum, bcth public 
and private, in the Territory of Washington, with suitable material for writing, 
enclosing, sealing, stamping, and mailing letters sufficient for writing of one four- 
paged letter a week ; provided they request the same, unless they are otherwise 
furnished with it ; and all these letters shall be dropped by the writers themselves, 
accompanied by an attendant, when necessary, into a post-office box, provided by 
the Territory at the institution, in some place easily accessible to all the patients, 
and the contents of these boxes shall be collected at least as often as once a 
week, by an authorized post-office agent; and it is hereby the duty of the 
Superintendent of every insane asylum in the Territory of Washington, both 
public and private, to deliver or cause to be delivered to said person any letter 
or writing fur him or her directed ; provided, the physician in charge does not 
consider the contents of such letter dangerous to the mental condition of the 
patient. 



622 APPENDIX. 

Sec. 2282. — Upon Delivery of Patient Supermtendent must give Certifi- 
cate, Stating Name of Patient and County. 

Whenever any patient is delivered at the asylum under the provision of this 
act, the Superintendent of this asylum shall give to the Sheriff or guard deliv- 
ering such patient, from what county admitted, and the Court that committed 
the same. 

LAWS OF WASHINGTON, 1883. 

Sec. 1632. — The Probate Court of any county in this Territory, or the Judge 
thereof, upon application, or any person under oath, setting forth that any person 
by reason of insanity is unsafe to be at large, or is suffering under mental 
derangement, shall cause such person to be brought before said Court or Judge, 
at such 'time and place as the Court or Judge may direct, and shall cause to 
appear at said time and place one or more respectable physicians, who shall 
under oath, in writing, give their opinion of the case, which opinions shall be 
carefully preserved and filed with other papers in the case, and if the said 
physician or physicians shall certify to the insanity or idiocy of said person, and 
it appear to the satisfaction of the Court, or Judge, that such is the fact, said 
Court or Judge shall cause such insane or idiotic person to be taken to and 
placed in the Hospital for the Insane of Washington Territory; provided, that 
such person, or any person in his behalf, may demand a jury to decide upon 
the question of his insanity; and the Court or Judge shall discharge such 
person if the verdict of the jury is that he is not insane : provided also, that 
when the relations or friends desire to take charge of such insane or idiotic 
person, the Court or Judge may so order, if they shall give bonds, to be 
approved by said Judge, conditioned that such insane or idiotic person shall be 
well and securely kept. 

AMENDED CODE OF WEST VIRGINIA, 1884. 

Chapter 58. — Section 7. — West Virginia Hospital for the Insane. 

A Superintendent, and as many assistants as may be necessary, who shall be 
physicians, and other officers, shall be appointed by the Board, and shall receive 
such compensation as the Board may prescribe. The Board may also appoint 
an executive committee, and may authorize the Superintendent to employ as 
many nurses and attendants as may be necessary, and also discharge them, or 
any of them, and employ others, but the Board shall fix their compensation; 
any one or more of the Directors, together with the Superintendent, shall con- 
stitute an Examining Board, and may examine persons brought to the asylum as 
lunatics, and order those found to be such to be received. 

Sec. II (Acts 1882, p. 133). — Any Justice who shall suspect any person 
in his county to be a lunatic, shall issue his warrant, ordering such person to 



LEGAL CARE OF THE INSANE. 623 

be brought before him. He shall inquire whether such person be a lunatic, 
and for that purpose summon a physician and other witnesses. In addition to 
any other questions he may propound as many of the following as may 
be applicable to the ca?e : 1. What is the patient's age, and where born ? 2. 
Is he married; if so, how many children has he? 3. What are his habits and 
occupation? 4. How long since have inclinations of insanity appeared? 5. 
What were they ? 6. Does the disease appear to increase? 7. Are there 
periodical exacerbations — any lucid intervals, and of what duration? 8. Is 
his derangement evinced on one or several subjects? what are they? 9. What 
is the supposed cause of his disease? 10. What change is there in his bodily 
condition since the attack? 11. Has there been a former attack; when, and 
of what duration? 12. Has he shown any disposition to commit violence to 
himself or others? 13. Whether any, and what restraint has been imposed 
on him ? 14. If any, what connections of his have been insane? were his 
parents or grandparents blood relations; if so, in what degree ? 15. Has he 
any bodily disease from suppressions of evacuations, eruptions, sores, injuries, 
or the like, and what is its history ? What curative means have been pursued, 
and their effects, and especially if depleting remedies, and to what extent have 
they been used ? 

Sec. 12. — If the said Justice decide that the person is a lunatic, and ought 
to be confined in the hospital, and that he is a citizen of the State, then, unless 
some person to whom the Justice, in his discretion, may deliver such lunatic, 
will give bond, with sufficient security, to be approved by said Justice, payable 
to the State, with condition to retain and take care of such lunatic, until the 
cause of confinement shall cease or the lunatic is delivered to the county, to 
be proceeded with according to law, the said Justice shall order him to be 
removed to the hospital and received, if there be room therein. 

Sec. 23. — When Persons may be Discharged from Hospital. 

Except in the case of a person charged with crime and subject to be tried 
therefor, or convicted of crime and subject to be punished therefor, when in a 
condition to be so tried or punished, the Board of the hospital, or the circuit 
of any county, may deliver any lunatic confined in the hospital or in the jail 
of such county, to any friend who will give bond with security, with the con- 
dition mentioned in the twelfth section of this chapter, and where a lunatic, 
except as aforesaid, is deemed by the Superintendent of the hospital both 
harmless and incurable, the Board may deliver him without such bond to 
any friend who is willing and, in the opinion of the Board, able to take care 
of him. 

Sec. 50. — General Provisions. 

If any Director of the hospital, Justice, clerk of a court, or other officers 
shall fail to perform any duty required of him in the chapter, or shall offend 



624 APPENDIX. 

against any prohibition contained herein, he shall forfeit not less than fifty nor 
more than one hundred dollars. 

Sec. 51. — The word " lunatic," whenever it occurs in this chapter, shall be 
construed to include every insane person who is not an idiot. 



REVISED STATUES OF WISCONSIN, 1879-1883. 

Chapter 32. — Section 588. — Duties of the Superintendent. 

The Superintendent of each hospital shall, before entering, upon the 
duties of his office, take and subscribe an oath, faithfully and diligently 
to discharge the duties required of him by law and the by-laws of the 
Board of Trustees. He shall be chief executive officer of the hospital, and 
shall devote all his time and attention to his duties; he shall exercise entire 
control over all the subordinate officers ; he shall employ all employees and 
assistants necessarily connected with the institution below the grade designated 
in the by-laws as officers, and may discharge any officer, assistant, or employee 
at will, being responsible to the Board of Trustees for the proper exercise of 
that duty in regard to officers. The Superintendent shall not be compelled to 
obey the subpoena of any court in any case, civil or criminal, if he shall 
file with the Magistrate or clerk his affidavit that to obey the same would be 
seriously detrimental and hazardous to the welfare of the hospital under his 
charge, except when an accusation of murder is to be tried ; nor in such case, 
unless the Judge shall make a special order therefor, and the subpoena, with 
a memorandum thereof endorsed thereon, be served one week before the time 
when he shall be required to appear ; provided, however, that no person shall 
be entitled, in any case, to make and file such affidavit, exempting him from 
subpoenas as aforesaid, who shall upon tender of the usual fees of witnesses, in 
courts of record, refuse to be present and to give his deposition at his office or 
usual place of business, or instead thereof, at his house or usual place of abode. 
Provided, further, that any person so present and giving his deposition at his 
office or usual place of business, or instead thereof at his house or usual place of 
abode, who shall be detained four hours from the time fixed for the taking of 
such deposition, or from the time to which the taking of the same may have 
been adjourned, may make affidavit that further detention would be seriously 
detrimental or hazardous to the welfare of the person or business in or under 
his charge; and such affidavit having been made, a Justice of the Peace, Court 
Commissaries, Notary Public, or other authorized officer before whom such 
deposition is given, shall thereupon adjourn further proceedings thereon to a 
future day. 

Sec. 593. — Proceedings to Determine Insanity ; Examiiiation by Physicians. 

Whenever any resident of this State, or any person from therein, whose resi- 



LEGAL CARE OF THE INSANE. 625 

dence cannot be ascertained, shall be or be supposed to be insane, application 
may be made in his behalf by any respectable citizen to the Judge of the 
County Court, Judge of the Circuit Court, or any Judge of a court of 
record in and for the county in which he resides, or, in case his residence 
is unknown, the county in which he is found, for a judicial inquiry as to 
his mental condition, and for an order of commitment to some hospital or 
asylum for insane. The application shall be in writing and shall specify 
whether or not a trial by Judge is desired by applicant. On receipt of 
said petition the Judge to whom it is addressed shall appoint two disin- 
terested physicians, of good repute for medical skill and moral integrity, 
to visit and examine the person alleged to be insane, and such physicians 
shall proceed without unnecessary delay to the residence of the person 
supposed to be insane, and shall by personal examination and inquiries 
satisfy themselves as to his condition and report the result of their examina- 
tion to the Judge. ********** 

Sec. 593. * * * * Upon the receipt of the report of the 
examining physicians, the Judge may, if no demand has been made for a jury, 
make and enter his order of commitment to the hospital or asylum of the 
district to which the county belongs, or if not fully satisfied, he may make 
such additional investigation of the case as may seem to him to be necessary 
and proper, and at any stage of the proceedings, and before the actual confine- 
ment of the person alleged to be insane, he, or any relative or friend acting 
in his behalf, shall have the right to demand that the question of sanity be 
tried by a jury, and when such demand is made, the Judge shall forthwith 
enter an order for a jury trial. 

In case a trial by jury is demanded, the forms of procedure shall be the 
same as in trials by jury in Justices' courts, and the trial shall be in the pres- 
ence of the person supposed to be insane, and his counsel and immediate 
friends and the medical witnesses. * * * * 

Sec. 593. — County Jtidge may Order Insane Persons Confined. 

On receipt by the County Judge of the petition provided for by Section I, of 
Chapter 266, of the General Laws of 1880, such Judge may, if in his opinion 
the public safety requires it, deliver to the Sheriff of his county an order in 
writing, requiring him forthwith to take and confine such insane or supposed 
insane person in some place to be specified, until further order of the Judge, 
and after the receipt by such Judge of the report of the examining physicians 
provided for in said chapter, such Judge may, in his discretion, deliver to such 
officer such order in writing requiring him forthwith to take such person into 
custody, and keep him in some place to be specified, until the further order of 
such Judge. The examining physicians provided for by said Section I, of 
said Chapter 266, in addition to the report required to be made by them by 

53 



626 APPENDIX. 

said section, shall state as follows : Has the patient any infectious disease ? In 
your opinion is he insane ? 

Sec. 593. — If any relative or friend — being of a legal age and competent to 
perform the duties — of any person committed to any hospital for the insane 
shall request the warrant for such commitment may be delivered to and 
executed by him, he shall be paid his necessary expenses, not exceeding 
the fees and expenses now allowed to sheriffs according to law; otherwise it 
shall be delivered to the Sheriff who, taking such assistants as the courts issuing 
such warrants may deem necessary, shall receive such insane person and 
convey him to the hospital. 



REVISED STATUTES OF WYOMING, 1887. 

Section 2287. — Application for Inquisition. 

If information in writing be given to the Probate Judge, that any person in 
the county is an idiot, lunatic, or person of unsound mind, or an habitual drunk- 
ard, or incapable of managing, and praying that an inquiry thereinto be had, 
the court,. if satisfied that theie be good cause for the exercise of its jurisdic- 
tion, shall cause the facts to be inquired into by a jury. 

Sec. 2288. — Court may act in Vacation. 

Such information may also be given in the vacation of said court, to the 
Judge therefor, in which event he shall call a special term of the court for the 
purpose of holding an inquiry, whether the person mentioned in such informa- 
tion be of unsound mind, or an habitual drunkard, or not. 

Sec. 2289. — Person may be Brought into Court. 

In proceeding under this chapter the Probate Court may, in its discretion, 
cause the person alleged to be of unsound mind or habitual drunkard to be 
brought before the Court. 

Sec. 2290. — Whenever any Judge of the Probate Court, Justice of the 
Peace, Sheriff, Coroner, or Constable, shall discover any person resident of his 
county to be of unsound mind or an habitual drunkard, as in the first section 
of this chapter mentioned, it shall be his duty to make application to the Pro- 
bate Court for the exercise of its jurisdiction, and thereupon the like proceed- 
ings shall be had as in the case of information by unofficial persons. 

1888. 

Chapter 85. — Section i. — That Section number thirty-seven hundred and 
sixty-five of the Revised Statutes of Wyoming be amended and revised, so as 
to read as follows : Section 3765. After the building herein provided for shall 
have been completed and accepted by the Board of Commissioners, the Board 
shall serve notice in writing upon the Boards of County Commissioners of all 



LEGAL CARE OF THE INSANE. 627 

the different counties in this Territory, which notice shall state that the Asylum 
for Insane at Evanston is now completed, and ready for the reception and care of 
insane persons. Each Board of County Commissioners shall, after the receipt 
of such notice, cause all persons adjudged to be insane, and whose care shall 
have been thrown upon the county, to be sent as patients to the Insane Asylum 
at Evanston, there to be kept and cared for at the expense of said county. And 
all insane persons having been sent to asylums outside of this Territory shall, 
upon the completion of said asylum at Evanston, and notice to the Board of 
County Commissioners as hereinbefore provided, be returned as soon as prac- 
ticable, under an order of the respective Boards of County Commissioners, to 
this county, to be kept and cared for at the Insane Asylum at Evanston. 

Skc. 3764. — 18S7. — Superintendent of Asylums; Qualifications and 
Duties. 

The Board of Commissioners shall elect one resident physician, who shall 
be the General Superintendent of the insane asylum herein provided for, 
subject at all times to the order and duties of said board, which shall have 
power at any time, whenever in their judgment it shall be deemed proper and 
for the best interests of the Territory, to discharge and remove such Superinten- 
dent. The Superintendent so elected shall reside at the asylum, be a 
graduate in medicine, and receive a salary of eighteen hundred dollars per year, 
payable in advance in equal instalments. He shall cause to be kept a fair and 
full account of all his doings, and the actual business and operations of the 
institution, and submit a monthly report to the Board of Commissioners. The 
Superintendent shall employ all necessary help needed at the Asylum, subject 
to the approval of the Board of Commissioners. 

Sec. 3766. — Paying patients, whose friends offer and will pay, or who have pro- 
perty to pay their expenses, shall be admitted to the insane asylum, according 
to the terms directed by the Board of Commissioners thereof; but the insane 
poor shall in all respects receive the same medical care and treatment, and be 
given as wholesome food, as is given to paying patients. 



INDEX. 



Activity, molecular, 34, 39 
automatic, 38 
functional, 46 
Actual cautery in treatment of general 

paresis, 523 
Acute alcoholic insanity, 425 
delirium, 528 

morbid appearances of, 537 
aetiology of, 530 
diagnosis of, 539. 
treatment of, 540 
Adolescence, period of, 276 

characteristics of, 277 
Adolescent insanity, 273 

reasons for infrequency of, 

280 
aetiology of, 274, 275 
motor activity in, 276 
symptoms of, 282 
tendency to recurrence in, 

285, 296 
treatment of, 298 
prophylaxis of, 299 
.'Etiology of general paresis, 451 
Age, influential in averting acute 
dementia, 228 
a factor in the aetiology of general 
paresis, 452, 453 
Alabama, laws of, in relation to the 

care of the insane, 555 
Alcohol a cause of insanity, 423 
Alcoholic paresis, 439 et seq. 

diagnosis of, 439 et seq. 
characteristics of, 439 
insanity, chronic, 431 
peripheral neuritis, 441 
Alimentation, importance of, in mania, 

200 
Alternating insanity, 248, 249 



Ammonium, bromide of, in mania, 98 
Anemia from insanity in lactation, 365 
Appetite in general paresis, 501 
Arizona, laws of, in relation to the 

insane, 557 
Arkansas, laws of, in relation to the 

care of the insane, 558 
Arrangement of mental diseases, 121 
Arsenic in melancholia, 165 
Artificial feeding in melancholia, 162 
Ascher, Dr., on syphilis and general 

paresis, 462, 463 
Assimilation in general paresis, 501 
Attention in mania, 186 

impairment of, in general paresis, 

479 
Auditory nerve, anatomy of, 30 
Aura epileptica, 396 



Baillarger on recurrent insanity, 244, 

251 
on periods of lucidity, 251 
on acute bed sores in general 
paresis, 504 
Ball on forms of insistent ideas, 78 
on folie circulaire, 246 
on folie alternante, 249 
Bannister, Dr., on the racial element 

in general paresis, 459 
Baths in mania, 198 
Bell, Luther V., on acute delirium, 

528 
Blood-vessels in old age, 305, 306 et 

seq. 
Boismont, M. Brierre de, on inter- 
mittent insanity, 249 
Bone, fractures in general paresis, 505 
Brain, development of, 278 



629 



630 



INDEX. 



Brain, diminution in volume of, 516 
fissures of, 1 1 
grey matter of, 13, 15 
hemispheres of, 1 1 
Briand on morbid anatomy of acute 

delirium, 538 
Bromides in treatment of general 
paresis, 523, 526 
in epilepsy, 418 
in mania, 199, 200 
in masturbation, 390 
Browne, Sir Crichton, on post-appear- 
ances in general paresis, 417 
Bucknill, John Charles, vii 
Buel, Dr. W. H., on recovery in a 
case of melancholia of twelve 
years' standing, 157 



Caesar an epileptic, 403 

California, laws relating to the insane, 
560 

Cannabis Indica in mania, 200 

Catamenia in adolescent insanity, 295 

Causes of general paresis in seventy- 
four cases, 463 

Characteristics of adolescence, 277, 
278 
of epileptics, 493, 400, 401 
of aura epileptica, 397 

Children, physical and mental de- 
velopment of, 277, 278 

Chlpral in mania, 198 

Chomel on post-febrile insanity, 544 

Chronic alcoholic insanity, 431 

character of delusions in, 432, 

433 
Classification of mental diseases, 121 
arrangement of, 121 
nomenclature of, 113 
Climacteric insanity, 322 
Clouston, Dr. T. S., on definition of 
insane delusion, 89 
on delusions in melancholia, 138 
Colorado, laws of, relating to the in- 
sane, 561 
Comparison of different localities in 
relation to general paresis, 459 
Connecticut, laws of, relating to the 
insane, 562 



Connoly, Dr., on sexual excesses a 

cause of general paresis, 460 
Convolutions of brain, 13 
Corpus striatum, 24 

functions of, 25 
nerve cells of, 25 
Cortex, 44 

cerebri, anatomy of, 15 
Cowles, Dr. Edward, on insistent 

ideas, 73 
Crises in acute delirium, 533 
Cullen on classification of diseases, 
no 



Dagonet on melancholia in northern 

climates, 128 
Definition of general paresis, 451 

of dementia, 258 

of mania, 168 

of melancholia, 127 
Delaware, laws of, relating to the in- 
sane, 567 
Delirium, acute, 126 

definition of, 530 

in children, 542 

of typhoid fever, 543 
Delusions, 87 

character of, 93 

definitions of, 89 

evolution of, 90 

expansive or depressive, 96 

subject matter of, 92 

transient or enduring, 101 

in general paresis, 480, 481 
Dementia, 112, 126, 257 

definition of, 258 

in general paresis, 478 

three forms of, 264 et seq. 

in epilepsy, 407 

delusions in, 263 

primary, 265 

secondary, 265 

prognosis in, 269 

symptoms of, 259 et seq. 

treatment of, 270 
Depression in folie circulaire, 247 
Derangement of the functional activ- 
ity of the brain an initial ele- 
ment of insanity, 47 



INDEX. 



63I 



Diagnosis of alcoholic paresis, 439 et 
seq. 

Diet in mania, 200 

in general paresis, 526 

Digitalis in treatment of general pa- 
resis, 526 

Dose of morphine, 444 



Egotism in general paresis, 470, 471 
Ecker, convolutions of, 13 
Ego, its signification, 42 
Emotions of fear, frequency of, 77 
Encephalon, 10 

Enemata, importance of in melan- 
cholia, 161 

in acute delirium, 535 
Energy, " specific," 34 
Epencephalon, 13 

Epileptic attacks in general paresis, 
492 

fury, 405, 406 

insanity, 392 
Epochs of life, 273, 274 
Esquirol on frequency of hallucina- 
tions, 60, 116, 257 

definition of dementia, 258 

on monomania, 117 
Evarts, Dr. O., on nature of the ego, 

43 
Evolution, method of, in delusions, 90 
Exciting causes of general paresis, 460 
Excitement in folie circulaire, 245 

in general paresis, 486 
Exercise, regularity in physical, im- 
portance of, 84 
Extravagant projects in general pa- 
resis, 470 



Falret on folie circulaire, 244' 

Flint, Dr. Austin, on treatment of 

morphine habit, 448 
Florida, laws of, relating to the in- 
sane, 568 
Folie alternante, 249 
circulaire, 126 

character of, 242 
aetiology of, 244 



Folie circulaire, frequency of, 242 
prognosis in, 255 
symptoms of, 245 
Folsom, Dr. Charles, on syphilis as a 

cause of general paresis, 461 
Food, importance of, in melancholia, 
163, 164 
in lactational insanity, 376 
in post-febrile insanity, 546 
Force, nerve, 47 

Functions of nerve cell and nerve 
contrasted, 35 



Ganglia, basal, 44 
Gastritis, 435 

Georgia, laws of, relating to the in- 
sane, 570 
Grand mal, 402, 404, 405 

climacteric, characteristics of, 323 
et seq. 
in females, 325 
Graves, Dr., on feeding in fevers, 546 
Grey matter of the brain, 13, 15 
Griesinger on definition of hallucina- 
tions, 48 
on automatic activity of brain in 
mania, 179 



H 



Hallucinations, 48 

of sight, 53 

of general sensation, 55 

of smell, 54 

of sexual organs, 55 

of taste, 54 

the import of, 56 

degree and importance of, 58 

intensity of, 59 

frequency of, 61 

in acute alcoholic insanity, 427 

in chronic alcoholic insanity, 433 

in general paresis, 481, 482 
Hammond, Dr. Wm. A., on aura 

epileptica, 398 
Handwriting of general paretics, 492 

et seq. 
Headache in general paresis, 467 
H ecker on dancing mania, 409 



632 



INDEX. 



Hemispheres of the brain, 11 

Heredity a factor of causation in gen- 
eral paresis, 453, 454 

Hochwart, von, Frank, on insanity 
after eye operations, 549 

Homicidal mania in epilepsy, 412 

Hot baths in mania, 198 

Howden, Dr. James C., on epilepsy, 
408 

Hurd, Dr. Henry M., on remissions 
in general paresis, 508 
a case by, 75 

Hyoscine in mania, 198 
in acute delirium, 535 

Hypophosphites in melancholia, 165 
in masturbatic insanity, 391 

Hysterical insanity, 126 



Identity, personal, 43 

Illinois, laws relating to the care of 

the insane, 572 
Illusions, 48 

definition of, 62 
of sight, 63 

of visceral sensibility, 64 
Imperative concepts, 66 

mode of origin, 67 
forms of disease in, 68 
prognosis and course of, 69 
Impulse, homicidal, 72. 
Incoordination in general paretics, 

475. 49 6 
Incubative stage in mania, 169 
Indiana, laws of, relating to the insane, 

574 
Inhibitory centres in adolescent in- 
sanity, 282. 
Initial periods of general paresis, 464 
"Insane foreigners," 529 
Insanity of masturbation, 377 

puerperal, 126 

delusional, 52, 126 

of puberty, 126 

climacteric, 126 

primary delusional, 202 

masturbatic, 126 

adolescent, 273 

post-febrile, 541 

alcoholic, 421 



Insanity, epileptic, 392 
senile, 126, 302 

Insistent ideas, 72 

formation and progressof,72 
characteristics of, 73 
treatment of, 82 

Insomnia in general paresis, 473 

Iowa, laws of, relating to the insane, 

579- 
Ivernes, M., on statistics of alcoholic 
insanity, 423, 424 



Jackson, Hughlings, on size and shape 
of cells related to functions, 
26 
Dr. J. B. F., on morbid anat- 
omy of acute delirium, 529 

Jacobi on instinctive character of con- 
duct in mania, 179 

Jeanne d'Arc, a remarkable case of 
hallucinations of hearing, 57 



Kansas, laws of, relating to the in- 
sane, 577 

Kentucky, laws of, relating to the in- 
sane, 578 

Kiernan, Dr. James S., on depression 
in general paresis, 473, 474 

Krafft-Ebing, on characteristics of 
insistent ideas, 82 
on transformations in primary de- 
lusional insanity, 233 
on curable and incurable states 
as a basis of classification, 121 



Labor for the chronic insane, 271 

Lane, Dr. Edward B., on hallucina- 
tions of the insane, 60 

La Salpetriere, epileptics in, 392 

Laws, definition of, 37 

Layers of cortex, 16, 18 

Lead poisoning, symptoms of, 515 

Lewis, Dr. W. Bevan, 26 
on phagocytes, 518 

Liebermeister on classification of dis- 
ease, in 

Lobes of the brain, 12, 13 



INDEX. 



633 



M 

Maine, laws of, relating to the caie of 

the insane, 580 
Malades atteints de delire du 

toucher, 79 
Mania, 126, 166 

definition of, 168 

acute, 45, 52 

course of, 188 

physical symptoms of, 170 

hallucinations of, 175 

aetiology of, 168 

mode of invasion of, 127 

symptoms, 130 

prognosis of, 156 

counter-irritation in, 1 91 

remittent, type of, 189 

treatment of, 191 

chronic, 193 

cases of, in the Retreat, 195 

recovery from, 195 

prognosis of, 196 

chloral in, 198 

hyoscine in, 198 

hot baths in, 198 

wet pack in, 198 

paraldehyde in, 198 

idiopathic acute, 112 
chronic, 112 

sympathetic, 112, 

intermittent, 1 12 

malarial fever in, 112 

bilious fever in, 113 
Maryland, laws of, relating to the 

insane, 582 
Massachusetts, laws of, relating to the 

insane, 582 
Maudsley, Dr. H., on sexual excess 
as a cause of general paresis, 460 
Medication in general paresis, 525 
Medicine in treatment of senile in- 
sanity, 320 
Medulla oblongata, 13 
Medullary substance, 20 
Medullated nerve fibres, 27 
description of, 28 
Melancholia, mode of invasion in, 127 

definition of, 127 

aetiology of, 127 

enemata in, 164 

management of, 83 

54 



Melancholia, opium in, i6r, 162 

hypophosphites in, 165 

symptoms of, 130 

prognosis of, 156 

treatment of, 159 
Memory in senile insanity, 309, 310 
Mental diseases, classification of, 109 

arrangement of, 121 
Metencephalon, 13 
Meynert on anatomy of the brain, 10 

on layers of the cortex, 16 
Michigan, laws of, relating to the 

insane, 585 
Mickle on acute bed-sores in general 
paralysis, 504 

on vertigo in general paralysis, 

475 

Mind-reading, 221 

Minnesota, laws of, relating to the 
insane, 585 

Mississippi, laws of, relating to the 
insane, 590 

Missouri, laws of, relating to the in- 
sane, 591 

Molecular activity and sensation, 33 
and thought, 35 et seq. 
in demonstrating geomet- 
rical problems, 40, 41 

Monomania, 117 

Montana, laws of, relating to the in- 
sane, 592 

Morbid anatomy of general paresis, 
515^/ seq. 

Morel on classification of mental dis- 
eases, III 

" Morphine habit," 444 

Morphinism, 442 

mode of invasion, 443 

Mydriasis in general paresis, 496 

N 

Napoleon an epileptic, 403 
Nature and source of mind, 43 
Nebraska, laws of, relating to insane, 

594 
Nerve cells, 18, 19 

description of, 18, 20 

functions of, 35 

in old age, 306 
Nerve fibres of the frog, 28 
Nerves, afferent and efferent, 44 



634 



INDEX. 



Nerves of sensation, 27 

motor, 27 
Nervous energy, nature of, 46, 47 
Nervous system, 10 
Neurosis as an setiological factor of 
disease, 122 

epileptica, 392 
Nevada, laws of, relating to insane, 

595 

New England asylums, general paret- 
ics in, 456 

" New form of disease," 528 

New Hampshire, laws of, relating to 
insane, 596 

New Jersey, laws of, relating to in- 
sane, 599 

New Mexico, laws of, relating to in- 
sane, 601 

New York Asylums, general paretics 
in, 457 

New York, laws of, relating to insane, 

597 
Nichols, Dr. C. H., on acute delir- 
ium, 529 
Nomenclature, 113 

Nomenclature and classification of 
disease, 113 
basis of, 114 
principles of, 115 
North Carolina, laws of, relating to 
insane, 602 



Obersteiner on central nervous or- 
gans, 10 
Ohio, laws of, relating to the insane, 

604 
Old age, characteristics of, 202, 203, 
204 
diminution of functional ac- 
tivity in, 315 
occasional increase of brain 

function in, 309 
impairment of perception in, 

308 
condition of nerve cells in, 

306 
memory in, 309, 310 
Opium in climacteric insanity, 340 
in melancholia, 161, 162 



Optic nerve, physiological activities 
of, 30 
thalami, 21 

anatomy of, 22, 23 
functions of, 23 
Oregon, laws of, relating to the in- 
sane, 606. 



Paraldehyde in mania, 198 
Paranoia, 119 
Paralysis, general, 126 

of ocular muscles in general 
paresis, 497 
Paresis, general, appearance of symp- 
toms in, 513 
actual cautery in, treatment 
of, abnormal dilatation, 
contraction, and insensi- 
bility of pupils in, 492 
accommodation in failure of, 

497 
atrophy of optic nerve in, ad- 
hesion of pia-mater in, 5 16 
assimilation in, 501 
acute bed-sore in, 504 
appetite in, 501 
periods of lucidity in, 251 
bone fractures in, 505 
cause of death in, 505 
cannabis indica in treatment 

of, 526 
diet in, 526 

digitalis in treatment of, 526 
diagnosis of, 510 et seq. 
duration of, 509, 510 
eye symptoms in, 496 
epileptiform seizures in, 492 
incoordination in, 496 
increase of adipose tissue in, 

496 
inflammatory origin of, 517 
remissions in, 507 
handwriting of, 492 et seq. 
recoveries in, 520, 521 
vessels of pia-mater in, 517 
ventricles in, 519 
treatment of, 520 
paralysis of ocular muscles 
in, 497 



INDEX. 



635 



Paresis, general, progressive failure 
of sight in, 498 
period of wasting in, 498 
physical symptoms of, 500 
potassium iodide in treat- 
ment of, 523 
Pathology of epilepsy, 416, 417 
Pemphigus eruptions, 537 
Pennsylvania, laws of, relating to in- 
sane, 607 
Perception, an act of, 47 
Personal identity, 43 
Phenomena of the external world, how 

perceived, 34, 40 
Physical conditions in senile insanity, 

311 

symptoms in general paralysis, 

474, 490 
Post-febrile insanity, 541 

aetiology of, 544 

symptoms of, 546 et seq. 

prognosis in, 550 

treatment of, 551 
Primaere Verruecktheit, 119 
Prognosis in acute alcoholic insanity, 

43° 
in epileptic insanity, 415 
in masturbatic insanity, 389 
in petit mal, 402, 403 
Progressive transformation in mania, 
177 

R 
Ranney, Dr. W. H., on acute de- 
lirium, 529, 533 
Recoveries in folie circulaire, 255 

in general paresis, 520, 521 
Relation of insanity to disorders of 

the brain, 47 
Relations between states of mind and 

the sexual organs, 377 et seq. 
Remissions in general paresis, 507 
Responsibility in epileptics, 394, 495 
Rhode Island, laws of, relating to in- 
sane, 609 
Romberg on epileptic attacks, 408 



Sankey on remissions in general pa- 
resis, 508 

Saulle, M. Legrand du, on epilepsy, 
403, 410 



Savage, Dr. George H., on experi- 
ence with folie circulaire, 244 

Schneiderian membrane, physiological 
action of, 31 

Seclusion of general paretic patients, 

524 
Senile insanity, 312 

aetiology of, 314 
pathology of, affecting nerve 
cells andblood-vessels,3o6 
mental symptoms of, 308 
suicidal tendency in, 318 
melancholic form of, 319 
physical conditions in, 31 1 
treatment of, 319 
Sensation and molecular activity, 33 
Sex in general paresis, 451, 452 
Shephard, Dr., on sexual excesses in 

causing general paresis, 460 
Sibbald, Dr. John, on the classification 
of insanity, 112, 1 16 
on treatment of excitement, 199 
Skae, Dr. D., on classification of in- 
sanity, 112, 116 
Sodium bromide in mania, 198 
South Carolina, laws of, relating to 

the insane, 61 1 
Special position in causing general 

paresis, 454, 455 
Spencer, Herbert, size of organs in 
relation to power, 276 
on lines of least resistance in 
nervous action, 72 
Sphincters in general paresis, 501 
Spitzka on acute bed-sores in general 
paresis, 504 
on morbid appearances in general 
paresis, 520 
Spontaneity of purpose in old age, 303 
Strychnine in melancholia, 1 61 
j Stupor, characteristics of, 139 
I Subject matter of insane delusions, 
92 
Suicide, 154 

in melancholia, 152 
Sulci in monkeys and the higher or- 
ders of the mammalia, 15 
Summits of the gyri in general pare- 
sis, 518 
Surgical operations to relieve epilepsy, 
420 



6 3 6 



INDEX. 



Swedenborg, hallucinations of, 232 
on aura epileptica, 398, 399 

Symptoms in acute delirium, ^oetseq. 
in morphine habit, 445 et seq. 
in epileptic insanity, 396 
in chronic alcoholic insanity, 431 
et seq. 

Synonyms of general paresis, 450 



Table of causes in general paresis, 
462 

Tactile corpuscles, functions of, 29 

Taste, nerves of, 32 

Tennessee, laws of, relating to insane, 
613 

Testamentary capacity in senile in- 
sanity, 320 

Texas, laws of, relating to the insane, 
614 

Thought process, depends upon, 36, 

41 
Todd, Dr. John, 165 
Treatment of general paresis, 520 

of bed-sores in, 527 

of senile insanity, 319 
Trousseau on delirium in fevers, 541 
Tuberculosis, 113 
Tuke, D. H., vii 
Tuke, J. Batty, on suicidal tendency 

in puerperal insanity, 349 
Typhomania, 126 

U 

Utah, laws of, relating to care of in- 
sane, 616 



Van der Kolk on classification, in, 

112, 115 
Vaso-motor disturbances in decay of 
general paresis, 501, 502, 503 
Vermont, laws of, relating to the in- 
sane, 617 
Verruecktheit, primaere, 121 
Vertigo in general paralysis, 374 
Vesication in masturbation, 390 
Vesicles on body in acute delirium, 

533 
Vessels of the pia mater in general 

paresis, 517 
Violence in epilepsy, 409 
Virginia, laws of, relating to insane, 

619 
Visceral sensibility, hallucinations of, 

W 

Washington, laws of, relating to the 
insane, 627 

West Virginia, laws of, relating to in- 
sane, 622 

Wet pack in treatment of excitement, 
198 

White matter of the brain, 15 

Wilkes, Dr. Samuel, on aura epilep- 
tica, 400 

Williams, Dr. A. V., on acute delir- 
ium, 529 

Wisconsin, laws of, relating to insane, 
624 

Wyoming, laws of, relating to insane, 
626 



CATALOGUE No. 7. DECEMBER, 1892. 

A CATALOGUE 

OF 

Books for Students. 

INCLUDING THE 

? QULZ-COMPENDS ? 



CONTENTS. 



PAGE PAGR 

New Series of Manuals, 2,3,4,5 Obstetrics 10 



Anatomy, 

Biology, 

Chemistry 

Children's Diseases 

Dentistry, 

Dictionaries, 

Eye Diseases, 

Electricity, . 

Gynaecology, 

Hygiene, 

Materia Medica 



6 Pathology, Histology, 

11 Pharmacy, . . . .12- 

6 Physical Diagnosis, . .11 

7 Physiology, . . . .11 

8 Practice of Medicine, . 11, 12 
16 Prescription Books, . . 12 

8 ?Quiz-Compends ? . 14,15 

9 Skin Diseases, . . .12 
10 Surgery and Bandaging, . 13 

9 Therapeutics, . . 9 

9 Urine and Urinary Organs, 13 



Medical Jurisprudence, . 10 Venereal Diseases, . . 13, 
Nervous Diseases, 



PUBLISHED BY 



P. B'LAKISTON, SON & CO., 

Medical Booksellers, Importers and Publishers. 

LARGE STOCK OF ALL STUDENTS' BOOKS, AT 
THE LOWEST PRICES. 

1012 Walnut Street, Philadelphia. 



*#* For sale by all Booksellers, or any book will be sent by mail, 
postpaid, upon receipt of price. Catalogues of books on all branches 
of Medicine, Dentistry, Pharmacy, etc.. supplied upon application. 

Pnce 1 Scents } 3 °°° Q ucstlons on Medical Subjects. 



"An excellent Series of Manuals." — Archives of Gynecology. 

A NEW SERIES OF 

STUDENTS' MANUALS 

On the various Branches of Medicine and Surgery. 

Can be used by Students of any College. 

Price of each, Handsome Cloth, $3.00. Full Leather, $3.50 

The object of this series is to furnish good manuals 
for the medical student, that will strike the medium 
between the compend on one hand and the prolix text- 
book on the other — to contain all that is necessary for 
the student, without embarrassing him with a flood of 
theory and involved statements. They have been pre- 
pared by well-known men, who have had large experience 
as teachers and writers, and who are, therefore, well 
informed as to the needs of the student. 

Their mechanical execution is of the best — good type 
and paper, handsomely illustrated whenever illustrations 
are of use, and strongly bound in uniform style. 

Each book is sold separately at a remarkably low 
price, and the immediate success of several of the 
volumes shows that the series has met with popular 
favor. 

No. 1. SURGERY. 318 Illustrations. 

Third Edition. 

A Manual of the Practice of Surgery. By Wm. J. 

Walsham, m.d., Asst. Surg, to, and Demonstrator of 

Surg, in, St. Bartholomew's Hospital, London, etc. 

318 Illustrations. 

Presents the introductory facts in Surgery in clear, precise 
language, and contains all the latest advances in Pathology, 
Antiseptics, etc. 

" It aims to occupy a position midway between the pretentious 
manual and the cumbersome System of Surgery, and its general 
character may be summed up in one word — practical." — The Medi- 
cal Bulletin. 

"Walsham, besides being an excellent surgeon, is a teacher in 
its best sense, and having had very great experience in the 
preparation of candidates for examination, and their subsequent 
professional career, may be relied upon to have carried out his 
work successfully. Without following out in detail his arrange- 
ment, which is excellent, we can at once say that his book is an 
embodiment of modern ideas neatly strung together, with an amount 
of careful organization well suited to the candidate, and, indeed, to 
the practitioner." — British Medical Journal. 

Price of each Book, Cloth, $3.00 ; Leather, $3.50. 



THE NEW SERIES OF MANUALS. 



No. 2. DISEASES OF WOMEN. 150 Illus. 

NEW EDITION. 

The Diseases of Women. Including Diseases of the 
Bladder and Urethra. By Dr. F. Winckel, Professor 
of Gynaecology and Director of the Royal University 
Clinic for Women, in Munich. Second Edition. Re- 
vised and Edited by Theophilus Parvin, m.d., 
Professor of Obstetrics and Diseases of Women and 
Children in Jefferson Medical College. 150 Engrav- 
ings, most of which are original. 
" The book will be a valuable one to physicians, and a safe and 

satisfactory one to put into the hands of students. It is issued in a 

neat and attractive form, and at a very reasonable price." — Boston 

Medical and Surgical Journal . 

No. 3. OBSTETRICS. 227 Illustrations. 

A Manual of Midwifery. By Alfred Lewis Galabin, 
M.A., M.D., Obstetric Physician and Lecturer on Mid- 
wifery and the Diseases of Women at Guy's Hospital, 
London; Examiner in Midwifery to the Conjoint 
Examining Board of England, etc. With 227 Illus. 
" This manual is one we can strongly recommend to all who 
desire to study the science as well as the practice of midwifery. 
Students at the present time not only are expected to know the 
principles of diagnosis, and the treatment of the various emergen- 
cies and complications that occur in the practice of midwifery, but 
find that the tendency is for examiners to ask more questions 
relating to the science of the subject than was the custom a few 
years ago. * * * The general standard of the manual is high ; 
and wherever the science and practice of midwifery are well taught 
it will be regarded as one of the most important text-books on the 
subject." — London Practitioner. 

No. 4. PHYSIOLOGY. Fifth Edition. 

321 ILLUSTRATIONS AND A GLOSSARY. 
A Manual of Physiology. By Gerald F. Yeo, m.d., 

f.r.cs., Professor of Physiology in King's College, 

London. 321 Illustrations and a Glossary of Terms. 

Fifth American from last English Edition, revised and 

improved. 758 pages. 

This volume was specially prepared to furnish students with a 
new text-book of Physiology, elementary so far as to avoid theories 
which have not borne the test of time and such details of methods 
as are unnecessary for students in our medical colleges. 

" The brief examination I have given it was so favorable that I 
placed it in the list of text-books recommended in the circular of the 
University Medical College." — Prof. Lewis A. Stimson, m.d., 
S7 East 33d Street, New York. 

Price of each Book, Cloth, $3.00; Leather, $3.50. 



THE NEW SERIES OF MANUALS. 



No. 5. DISEASES OF CHILDREN. 

SECOND EDITION. 
A Manual. By J. F. Goodhart, m.d., Phys. to the 
Evelina Hospital for Children ; Asst. Phys. to 
Guy's Hospital, London. Second American Edition. 
Edited and Rearranged by Louis Starr, m.d., Clinical 
Prof, of Dis. of Children in the Hospital of the Univ. 
of Pennsylvania, and Physician to the Children's Hos- 
pital, Phila. Containing many new Prescriptions, a list 
of over 50 Formulae, conforming to the U. S. Pharma- 
copoeia, and Directions for making Artificial Human 
Milk, for the Artificial Digestion of Milk, etc. Illus. 

" The author has avoided the not uncommon error of writing a 
book on general medicine and labeling it ' Diseases of Children,' 
but has steadily kept in view the diseases which seemed to be 
incidental to childhood, or such points in disease as appear to be so 
peculiar to or pronounced in children as to justify insistence upon 
them. * * * A safe and reliable guide, and in many ways 
admirably adapted to the wants of the student and practitioner." — 
American Journal of Medical Science. 

No. 6. MATERIA MEDICA, PHARMACY, 
PHARMACOLOGY, AND THE- 
RAPEUTICS. 

JUST READY. 
A Handbook for Students. By Wm. Hale White,, 
m.d., f.r.c.p., etc., Physician to, and Lecturer on Ma- 
teria Medica, Guy's Hospital; Examiner in Materia 
Medica, Royal College of Physicians, London, etc. 
American Edition. Revised by Reynold W. Wilcox, 
m.a., m.d., Prof, of Clinical Medicine at the New York 
Post-Graduate Medical School and Hospital ; Assistant 
Visiting Physician Bellevue Hospital. 580 pages. 
In preparing this book, the wants of the medical student of to-day- 
have been constantly kept in view. The division into several sub- 
jects, which are all arranged in a systematic, practical manner, will 
be found of great help in mastering the whole. The work of the 
editor has been mainly in the line of adapting the book to the use 
of American students ; at the same time, however, he has added 
much new material. Dr. Wilcox's long experience in teaching 
and writing on therapeutical subjects particularly fits him for the 
position of editor, and the double authorship has resulted in mak- 
ing a very complete handbook, containing much minor useful in- 
formation that if prepared by one man might have been overlooked. 
Price of each Book, Cloth, $3.00 : Leather, $3.50. 



THE NEW SERIES OF MANUALS. 



No. 7. MEDICAL JURISPRUDENCE AND 
TOXICOLOGY. 

THIRD REVISED EDITION. 

By John J. Reese, m.d., Professor of Medical Jurispru- 
dence and Toxicology in the University of Pennsyl- 
vania ; President of the Medical Jurisprudence Society 
of Phila. ; Third Edition, Revised and Enlarged. 

" This admirable text-book." — Amer.Jour. of Med. Sciences. 

" We lay this volume aside, after a careful perusal of its pages, 
with the profound impression that it should be in the hands of every 

doctor and lawyer. It fully meets the wants of all students 

He has succeeded in admirably condensing into a handy volume all 
the essential points." — Cincinnati Lancet and Clinic. 

" The book before us will, we think, be found to answer the ex- 
pectations of the student or practitioner seeking a manual of juris- 
prudence, and the call for a second edition is a flattering testimony 
to the value of the author's present effort. The medical portion 
of this volume seems to be uniformly excellent, leaving little for 
adverse criticism. The information on the subject matter treated 
has been carefully compiled, in accordance with recent knowledge. 
The toxicological portion appears specially excellent. Of that por- 
tion of the work treating of the legal relations of the practitioner 
and medical witness, we can express a generally favorable ver- 
dict." — Physician and Surgeon , Ann Arbor, Mich. 

No. 8. DISEASES OF THE EYE. 176 Illus. 

FOURTH EDITION. JUST READY. 

Diseases of the Eye and their Treatment. A Handbook 
for Physicians and Students. By Henry R. Swanzy, 
a.m., MB., F R. c.s.i. , Surgeon to the National Eye and 
Ear Infirmary; Ophthalmic Surgeon to the Adelaide 
Hospital, Dublin; Examiner in Ophthalmic Surgery 
in the Royal University of Ireland. Fourth Edition, 
Thoroughly Revised. 176 Illustrations and a Zephyr 
Test Plate. 500 pages. 

" Mr. Swanzy has succeeded in producing the most intellectually 
conceived and thoroughly executed resume of the science within 
the limits he has assigned himself. As a 'students' handbook,* 
small in size and moderate in price, it can hardly be equaled." — 
Medical News. 

" A full, clear, and comprehensive statement of Eye Diseases 
and their treatment, practical and thorough, and we feel fully jus- 
tified in commending it to our readers. It is written in a clear and 
forcible style, presenting in a condensed yet comprehensive form 
current and modern information that will prove alike beneficial to 
the student and general practitioner." — Southern Practitioner. 

Price of each Book, Cloth, $3.00; Leather, $3.50. 



« STUDENTS' TEXT-BOOKS AND MANUALS. 

ANATOMY. 

Morris' New Text-Book on Anatomy. 700 Specially En- 
graved Illustrations, many of which are printed in colors. Edi- 
ted by Henry Morris, f.r c.s., and contributed to by many well- 
known writers. Octavo. Nearly Ready. Price about 6.00 
*#* Send for Descriptive Circular and Sample Pages. 

Macalister's Human Anatomy. 816 Illustrations. A new 
Text-book for Students and Practitioners, Systematic and Topo- 
graphical, including the Embryology, Histology, and Morphology 
of Man. With special reference to the requirements of 
Practical Surgery and Medicine. With 816 Illustrations, 
400 of which are original. Octavo. Cloth, 7.50; Leather, 8.50 

Ballou's Veterinary Anatomy and Physiology. Illustrated. 
By Wm. R. Ballou, m.d., Professor of Equine Anatomy at New 
York College of Veterinary Surgeons. 29 graphic Illustrations. 
i2mo. Cloth, 1. 00; Interleaved for notes, 1.25 

Holden's Anatomy. A manual of Dissection of the Human 
Body. Fifth Edition. Enlarged, with Marginal References and 
over 200 Illustrations. Octavo. 

Bound in Oilcloth, for the Dissecting Room, $4.50. 

Holden's Human Osteology. Comprising a Description of the 
Bones, with Colored Delineations of the Attachments of the 
Muscles. The General and Microscopical Structure of Bone and 
its Development. With Lithographic Plates and Numerous Illus- 
trations. Seventh Edition. 8vo. Cloth, 6.00 

Holden's Landmarks, Medical and Surgical. 4th ed. Clo., 1.25 

Potter's Compend of Anatomy. Fifth Edition. Enlarged. 
16 Lithographic Plates. 117 Illustrations. See Page 14. 

Cloth, 1.00; Interleaved for Notes, 1.25 

CHEMISTRY. 

Bartley's Medical Chemistry. Second Edition. A text-book 
prepared specially for Medical, Pharmaceutical, and Dental Stu- 
dents. With 50 Illustrations, Plate of Absorption Spectra and 
Glossary of Chemical Terms. Revised and Enlarged. Cloth, 2.50 

Trimble. Practical and Analytical Chemistry. A Course in 
Chemical Analysis, by Henry Trimble, Prof, of Analytical Chem- 
istry in the Phila. College of Pharmacy. Illustrated. Fourth 
Edition, Enlarged. 8vo. Cloth, 1.50 

Bloxam's Chemistry, Inorganic and Organic, with Experiments. 
Seventh Edition. 281 Illustrations. Cloth, 4.50; Leather, 5.50 
M&~ See pages 2 to j for list 0/ Students' Manuals . 



STUDENTS' TEXT-BOOKS AND MANUALS. 



Chemistry : — Continued. 

Richter's Inorganic Chemistry. Fourth American, from Sixth 
German Edition. Translated by Prof. Edgar F. Smith, ph.d. 
89 Wood Engravings and Colored Plate of Spectra. Cloth, 2.00 

Richter's Organic Chemistry, or Chemistry of the Carbon 
Compounds. Illustrated. Second Edition. Cloth, 4.50 

Symonds. Manual of Chemistry, for the special use of Medi- 
cal Students. By Bkandreth Symonds, a.m., m.d., Asst. 
Physician Roosevelt Hospital, Out-Patient Department ; Attend- 
ing Physician Northwestern Dispensary, New York. Cloth, 2.00 

Leffmann's Compend of Chemistry. Inorganic and Organic. 
Including Urinary Analysis. Third Edition. Revised. 
See page 15. Cloth, 1.00; Interleaved for Notes, 1.25 

Leffmann and Beam. Progressive Exercises in Frsci.:cal 
Chemistry. 121110. Illustrated. Cloth, 1.00 

Muter. Practical and Analytical Chemistry. Fourth Edi- 
tion. Revised, to meet the requirements of American Medical 
Colleges, by Prof. C. C. Hamilton. Illustrated. Cloth, 2.00 

Holland. The Urine, Common Poisons, and Milk Analysis, 
Chemical and Microscopical. For Laboratory Use. Fourth 
Edition, Enlarged. Illustrated. Cloth, 1.00 

Van Niiys. Urine Analysis. Illus. Cloth, 2.00 

CHILDREN. 

Goodhart and Starr. The Diseases of Children. Second 
Edition. By J. F. Goodhart, m.d., Physician to the Evelina 
Hospital for Children ; Assistant Physician to Guy's Hospital, 
London. Revised and Edited by Louis Starr, m.d., Clinical 
Professor of Diseases of Children in the Hospital of the Univer- 
sity of Pennsylvania; Physician to the Children's Hospital, 
Philadelphia. Containing many Prescriptions and Formulae, 
conforming to the U. S. Pharmacopoeia, Directions for making 
Artificial Human Milk, for the Artificial Digestion of Milk, etc. 
Illustrated. Cloth, 3.00; Leather, 3.50 

Hatfield. Diseases of Children. By M. P. Hatfield, m.d., 
Professor of Diseases of Children, Chicago Medical College. 
Colored Plate. i2mo. Cloth, 1.00; Interleaved, 1.25 

Starr. Diseases of the Digestive Organs in Infancy and 
Childhood. With hapters on the Investigation of Disease, 
and on the General ) magement of Children. By Louis Starr, 
m.d., Clinical Professor of Diseases of Children in the Univer- 
sity of Pennsylvania. Illus. Second Edition. Cloth, 2.25 
Jt&- See pages 14 and is for list of ? Quiz-Cotnpendsf 



8 STUDENTS* TEXT-BOOKS AND MANUALS. 

DENTISTRY. 

Fillebrown. Operative Dentistry. 330 Illus. Cloth, 2.50 

Flagg's Plastics and Plastic Filling. 4th Ed. Cloth, 4.00 
Gorgas. Dental Medicine. Fourth Edition. Cloth, 3.50 

Harris. Principles and Practice of Dentistry. Including 
Anatomy, Physiology, Pathology, Therapeutics, Dental Surgery 
and Mechanism. Twelfth Edition. Revised and enlarged by 
Professor Gorgas. 1028 Illustrations. Cloth, 7.00 ; Leather, 8.00 
Richardson's Mechanical Dentistry. Fifth Edition. 569 
Illustrations. 8vo. Cloth, 4.50; Leather, 5.50 

Sewill. Dental Surgery. 200 Illustrations. 3d Ed. Clo., 3.00 
Taft's Operative Dentistry. Dental Students and Practitioners. 
Fourth Edition. 100 Illustrations. Cloth, 4.25 ; Leather, 5.00 
Talbot. Irregularities of the Teeth, and their Treatment. 
Illustrated. 8vo. Second Edition. Cloth, 3.00 

Tomes' Dental Anatomy. Third Ed. 191 Illus. Cloth, 4.00 
Tomes' Dental Surgery. 3d Edition. 292 Illus. Cloth, 5.00 
Warren. Compend of Dental Pathology and Dental Medi- 
cine. Illustrated. Cloth, 1.00; Interleaved, 1.25 

DICTIONARIES. 

Gould's New Medical Dictionary. Containing the Definition 
and Pronunciation of all words in Medicine, with many useful 
Tables etc. % Dark Leather, 3.25 ; %. Mor., Thumb Index, 4.25 

Gould's Pocket Dictionary. 12,000 Medical Words Pro- 
nounced and Defined. Containing many Tables and an 
Elaborate Dose List. Thin 64mo. fust Ready. Leather, 1.00 

Harris' Dictionary of Dentistry. Fifth Edition. Completely 
revised by Prof. Gorgas. Cloth, 5.00; Leather, 6.00 

Cleaveland's Pronouncing Pocket Medical Lexicon. Small 
pocket size. Cloth, red edges .75 , pocket-book style, 1.00 

Longley 's Pocket Dictionary. The Student's Medical Lexicon, 
giving Definition and Pronunciation, with an Appendix giving 
Abbreviations used in Prescriptions, Metric Scale of Doses, etc. 
24mo. Cloth, 1. 00; pocket-book style, 1.25 



EYE. 

Hartridge on Refraction. 5th Edition. Illus. Cloth, 2.00 

Swanzy. Diseases of the Eye and their Treatment. 176 

Illustrations. Fourth Edition. Cloth, 3 00; Leather, 3 50 

Fox and Gould. Compend of Diseases of the Eye and 

Refraction. 2d Ed. Enlarged. 71 Illus. 39 Formulae. 

Cloth, 1. 00 ; Interleaved for Notes, 1.25 
.ftS* See Pages 2 to 5 for list of Students' Manuals. 



STUDENTS' TEXT-BOOKS AND MANUALS. 9 

ELECTRICITY. 

Bigelow. Plain Talks on Medical Electricity. Cloth, i.oo 

Mason's Compend of Medical Electricity. Cloth, i.oo 

Steavenson and Jones. Medical Electricity. A Practical 

Handbook. Just Ready. Illustrated. i2mo. Cloth, 2.50 

HYGIENE. 

Coplin and Bevan. Practical Hygiene. By W. M. L. Cop- 
lin, Adjunct Professor of Hygiene, Jefferson Medical College, 
Philadelphia, and Dr. D. Bevan. Illustrated. In Press. 

Parkes' (Ed. A.) Practical Hygiene. Seventh Edition, en- 
larged. Illustrated. 8vo. Cloth, 4.50 

Parkes' (L. C.) Manual of Hygiene and Public Health. 
Second Edition. i2mo. Cloth, 2.50 

■Wilson's Handbook of Hygiene and Sanitary Science. 
Seventh Edition. Revised and Illustrated. Cloth, 3 25 

MATERIA MEDICA AND THERAPEUTICS. 

Potter's Compend of Materia Medica, Therapeutics, and 
Prescription Writing. Fifth Edition, revised and improved. 
See page 15. Cloth, 1.00; Interleaved for Notes, 1.25 

Davis. Essentials of Materia Medica and Prescription 
Writing. By J. Aubrey Davis, m.d., Demonstrator of Obstet- 
rics and Quiz-Master on Materia Medica, University of Penn- 
sylvania. i2mo. Interleaved. Net, 1.50 

Biddle's Materia Medica. Twelfth Edition. By the late 
John B. Biddle, m.d. Revised by Clement Biddle, m.d. 8vo. 
Illustrated. Cloth, 4.25; Leather, 5.00 

Potter. Handbook of Materia Medica, Pharmacy, and 
Therapeutics. Including Action of Medicines, Special Thera- 
peutics, Pharmacology, etc. By Saml. O. L. Potter, m.d., 
m.r c.P. (Lond), Professor of the Practice of Medicine in 
Cooper Medical College, San Francisco. Fourth Revised and 
Enlarged Edition. 776 pages. 8vo. Cloth, 4.00; Leather, 5.00 

White and Wilcox. Materia Medica, Pharmacy, Phar- 
macology, and Therapeutics. A Handbook for Students. 
By \Vm. Hale White, m.d., f.k.c.p., etc., Physician to and 
Lecturer on Materia Medica, Guy's Hospital. Revised by 
Reynold W. Wilcox, m.d., Professor of Clinical Medicine at the 
New York Post Graduate Medical School, Assistant Physician 
P.ellevue Hospital, etc. American Edition. Clo., 3.00; Lea., 3.50 
Jt9" See pages 14 and ij for list 0/ f Quiz- Compends ? 



10 STUDENTS' TEXT-BOOKS AND MANUALS. 

MEDICAL JURISPRUDENCE. 
Reese. A Text-book of Medical Jurisprudence and Toxi- 
cology. By John J. Reese, m.d., Professor of Medical Juris- 
prudence and Toxicology in the Medical Department of the 
University of Pennsylvania ; Physician to St. Joseph's Hospital. 
Third Edition. Cloth, 3.00; Leather, 3.50 

NERVOUS DISEASES. 

Gowers. Manual of Diseases of the Nervous System. 
A Complete Text-book. By William R. Gowers, m.d., Prof. 
Clinical Medicine, University College, London. Physician to 
National Hospital for the Paralyzed and Epileptic. Second 
Edition. Revised, Enlarged, and in many parts Rewritten. 
With many new Illustrations. Octavo. 

Vol. I. Diseases of the Nerves and Spinal Cord. 616 

pages. Cloth, 3.50 

Vol. II. Diseases of the Brain and Cranial Nerves. 

General and Functional Diseases. Nearly Ready. 

Ormerod. Diseases of Nervous System, Student's Guide to. 
By J. A. Ormerod, m.d., Oxon., f.r.c.p. (London), Member Path- 
ological, Clinical, Ophthalmological, and Neurological Societies, 
Physician to National Hospital for Paralyzed and Epileptic and 
to City of London Hospital for Diseases of the Chest, Demon- 
strator of Morbid Anatomy, St. Bartholomew's Hospital, etc. 
With 75 Wood Engravings. Cloth, 2.00 

OBSTETRICS AND GYNECOLOGY. 

Davis. A Manual of Obstetrics. By Edw. P. Davis, Clinical 
Lecturer on Obstetrics, Jefferson Medical College, Philadelphia. 
Colored Plates, and 130 other Illustrations. i2mo. Cloth, 2.00 

Byford. Diseases of Women. The Practice of Medicine and 
Surgery, as applied to the Diseases and Accidents Incident to 
Women. By W. H. Byford, a.m., m.d., Professor of Gynaecology 
in Rush Medical College and of Obstetrics in the Woman's Med- 
ical College, etc., and Henry T. Byford, m.d., Surgeon to the 
Woman's Hospital of Chicago. Fourth Edition. Revised and 
Enlarged. 306 Illustrations, over 100 of which are original. 
Octavo. 832 pages. Cloth, 5.00 ; Leather, 6.00 

Leavers' Diseases of Women. A Practical Text-book. 139 
Illustrations. Second Edition. Cloth, 2.50 

Parvin's Winckel's Diseases of "Women. Second Edition. 
Including a Section on Diseases of the Bladder and Urethra. 
150 Illus. Revised. See page 3. Cloth, 3.00; Leather, 3.50 

Morris. Compend of Gynaecology. Illustrated. Cloth, 1.00 

Winckel's Obstetrics. A Text-book on Midwifery, includ- 
ing the Diseases of Childbed. By Dr. F. Winckel, Professor 
of Gynaecology, and Director of the Royal University Clinic for 
Women, in Munich. Authorized Translation, by J. Clifton 
Edgar, m.d., Lecturer on Obstetrics, University Medical Col- 
lege, New York, with nearly 200 handsome Illustrations, the 
majority of which are original. 8vo. Cloth, 6.00; Leather, 7.00 

XS~ See pages 2 to 5 for list of New Manuals. 



STUDENTS' TEXT-BOOKS AND MANUALS. 11 



Obstetrics and Gynecology : — Continued. 
Landis' Compend of Obstetrics. Illustrated. 4th Edition, 
Enlarged. Cloth, 1.00; Interleaved for Notes, 1.25 

Galabin's Midwifery. By A. Lewis Galabin, m.d., f.r.c.f.. 
227 Illustrations. See page 3. Cloth, 3.00; Leather, 3.50 

PATHOLOGY, HISTOLOGY, ETC. 

Wethered. Medical Microscopy. By Frank J. Wethered, 
m.d., m.r.c.p. 98 Illustrations. Cloth, 2.50 

Bowlby. Surgical Pathology and Morbid Anatomy, for 
Students. 135 Illustrations. 12D10. Cloth, 2.00 

Gilliam's Essentials of Pathology. A Handbook for Students. 
47 Illustrations. i2mo. Cloth, 2.00 

Virchow's Post-Mortem Examinations. 3d Ed. Cloth, 1.00 

PHYSICAL DIAGNOSIS. 

Fenwick. Student's Guide to Physical Diagnosis. 7th 
Edition. 117 Illustrations. i2mo. Cloth, 2.25 

Tyson's Student's Handbook of Physical Diagnosis. Illus- 
trated. i2mo. Cloth, 1.25 

PHYSIOLOGY. 

Yeo's Physiology. Fifth Edition. The most Popular Stu- 
dents' Book. By Gerald F. Yeo, m.d., f.r.c.s., Professor of 



Physiology in King's College, London. Small Octavo. 758 
pages. 321 carefully printed Illustrations. With a Full 
Glossary and Index. See page 3. Cloth, 3.00; Leather, 3.50 



Brubaker's Compend of Physiology. Illustrated. Sixth 
Edition. Cloth, 1.00; Interleaved for Notes, 1.25 

Kirke's Physiology. New 13th Ed. Thoroughly Revised and 
Enlarged. 502 Illustrations, some of which are printed in colors. 
(Blakiston's Authorized Edition.) Cloth, 4.00; Leather, 5.00 

Landois' Human Physiology. Including Histology and Micro- 
scopical Anatomy, and with special reference to Practical Medi- 
cine. Fourth Edition. Translated and Edited by Prof. Stirling. 
845 Illustrations. Cloth, 7.00 ; Leather, 8.00 

" With this Text-book at his command, no student could fail in 

his examination." — Lancet. 

Sanderson's Physiological Laboratory. Being Practical Ex- 
ercises for the Student. 350 Illustrations. 8vo. Cloth, 5.00 

PRACTICE. 

Taylor. Practice of Medicine. A Manual. By Frederick 
Taylor, m.d., Physi' ian to, and Lecturer on Medicine at, Guy's 
Hospital, London ; Physician to Evelina Hospital for Sick Chil- 
dren, and Examiner in Materia Medica and Pharmaceutical 
Chemistry, University of London. Cloth, 2.00; Leather, 2.50 

$f9~ See Pages 14 and IJ for list of f Quiz-Compends f 



12 STUDENTS' TEXT-BOOKS AND MANUALS. 

Practice : — Continued. 

Roberts' Practice. New Revised Edition. A Handbook 
of the Theory and Practice of Medicine. By Frederick T. 
Roberts, m.d., m.r.c.p., Professor of Clinical Medicine and 
Therapeutics in University College Hospital, London. Seventh 
Edition. Octavo. Cloth, 5.50 ; Sheep, 6.50 

Hughes. Compend of the Practice of Medicine. 4th Edi- 
tion. Two parts, each, Cloth, 1.00; Interleaved for Notes, 1.25 
Part i. — Continued, Eruptive and Periodical Fevers, Diseases 

of the Stomach, Intestines, Peritoneum, Biliary Passages, Liver, 

Kidneys, etc., and General Diseases, etc. 
Part ii. — Diseases of the Respiratory System, Circulatory 

System, and Nervous System; Diseases of the Blood, etc. 

Physicians' Edition. Fourth Edition. Including a Section 
on Skin Diseases. With Index. 1 vol. Full Morocco, Gilt, 2.50 

From John A. Robinson, M.D., Assistant to Chair of Clinical 
Medicine, now Lecturer on Materia Medica, Rush Medical Col- 
lege, Chicago. 
" Meets with my hearty approbation as a substitute for the 

ordinary note books almost universally used by medical students. 

It is concise, accurate, well arranged, and lucid, . . . just the 

thing for students to use while studying physical diagnosis and the 

more practical departments of medicine." 

PRESCRIPTION BOOKS. 

Wythe's Dose and Symptom Book. Containing the Doses 
and Uses of all the principal Articles of the Materia Medica, etc. 
Seventeenth Edition. Completely Revised and Rewritten. Just 
Ready. 32mo. Cloth, 1. 00; Pocket-book style, 1.25 

Pereira's Physician's Prescription Book. Containing Lists 
of Terms, Phrases, Contractions, and Abbreviations used in 
Prescriptions, Explanatory Notes, Grammatical Construction of 
Prescriptions, etc., etc. By Professor Jonathan Pereira, m.d. 
Sixteenth Edition. 32mo. Cloth, 1.00; Pocket-book style, 1.25 

PHARMACY. 

Stewart's Compend of Pharmacy. Based upon Remington's 
Text-book of Pharmacy. Third Edition, Revised. With new 
Tables, Index, Etc. Cloth, 1.00 ; Interleaved for Notes, 1.25 

Robinson. Latin Grammar of Pharmacy and Medicine. 
By H. D. Robinson, ph.d., Professor of Latin Language and 
Literature, University of Kansas, Lawrence. With an Intro- 
duction by L. E. Sayre, ph.g., Professor of Pharmacy in, and 
Dean of, the Dept. of Pharmacy, University of Kansas. i2mo. 

Cloth, 2.00 
SKIN DISEASES. 

Anderson, (McCall) Skin Diseases. A complete Text-book, 
with Colored Plates and numerous Wood Engravings. 8vo. 

Cloth, 4.50; Leather, 5.50 

Van Harlingen on Skin Diseases. A Handbook of the Dis- 
eases of the Skin, their Diagnosis and Treatment (arranged alpha- 
betically). By Arthur Van Harlingen, m.d., Clinical Lecturer 
on Dermatology, Jefferson Medical College ; Prof, of Diseases of 
the Skin in the Philadelphia Polyclinic. 2d Edition. Enlarged. 
With colored and other plates and illustrations. i2mo. Cloth, 2.50 
i8®* See pages 2 to 5 for list of New Manuals. 



STUDENTS' TEXT-BOOKS AND MANUALS. 13- 
SURGERY AND BANDAGING. 

Moullin's Surgery. 500 Illustrations (some colored), 200 or 
which are original. 2d Ed. Cloth, net 7.00; Leather, net 8.00 

Jacobson. Operations in Surgery. A Systematic Handbook 
for Physicians, Students, and Hospital Surgeons. By W. H. A. 
Jacobson, B a. Oxon., f.r.c.s. Eng. ; Ass't Surgeon Guy's Hos- 
pital ; Surgeon at Royal Hospital for Children and Women, etc. 
199 Illustrations. 1006 pages. 8vo. Cloth. 5.00; Leather, 6.00 

Heath's Minor Surgery, and Bandaging. Ninth Edition. 142 
Illustrations. 60 Formulae and Diet Lists. Cloth, 2.00 

Horwitz's Compend of Surgery, Minor Surgery and 
Bandaging, Amputations, Fractures, Dislocations, Surgical 
Diseases, and the Latest Antiseptic Rules, etc., with Differential 
Diagnosis and Treatment. By Orville Hokwitz, b.s., m.d.. 
Demonstrator of Surgery, Jefferson Medical College. 4th edition. 
Enlarged and Rearranged. 136 Illustrations and 84 Formula?. 
i2mo. Cloth, 1.00 ; Interleaved for the addition of Notes, 1.25 
***The new Section on Bandaging and Surgical Dressings con- 
sists of 32 Pages and 41 Illustrations. Every Bandage of any 
importance is figured. This, with the Section on Ligation oi 
Arteries, forms an ample Text-book for the Surgical Laboratory. 

Walsham. Manual of Practical Surgery. Third Edition. 
By Wm. T. Walsham, m.d., f.r c s., Asst. Surg, to, and Dem 
of Practical Surg, in, St. Bartholomew's Hospital; Surgeon to 
Metropolitan Free Hospital, London. With 318 Engravings. 
See page 2. Cloth, 300; Leather, 3.50 

URINE, URINARY ORGANS, ETC. 

Holland. The Urine, and Common Poisons and The 
Milk. Chemical and Microscopical, for Laboratory Use. Illus- 
trated. Fourth Edition, umo. Interleaved. Cloth, 1.00 

Ralfe. Kidney Diseases and Urinary Derangements. 42 Illus- 
trations. i2mo. 572 pages. Cloth, 2.75 

Marshall and Smith. On the Urine. The Chemical Analysis ot 
the Urine. By John Marshall, m.d., Chemical Laboratory, Univ. 
of Penna; and Prof. E. F. Smith, ph.d. Col. Plates. Cloth, 1.00 

Memminger. Diagnosis by the Urine. Illustrated. 

Cloth, 1. 00 

Tyson. On the Urine. A Practical Guide to the Examination 
of Urine. With Colored Plates and Wood Engravings. 7th Ed. 
Enlarged. i2mo. Cloth, 1.50 

Van Niiys, Urine Analysis. Illus. Cloth, 2.00 

VENEREAL DISEASES. 

Hill and Cooper. Student's Manual of Venereal Diseases, 
with Formula. Fourth Edition. i2mo. Cloth, 1.00 

KS- See pages 14 and ij for list 0/ ? Quiz- Contpends f 



? 



?QUIZ-COMPENDS? 

The Best Compends for Students' Use 
in the Quiz Class, and when Pre- 
paring for Examinations. 

Compiled in accordance with the latest teachings of promi- 
nent Lecturers and the most popular Text-books. 

They form a most complete, practical, and exhaustive 
set of manuals, containing information nowhere else col- 
lected in such a condensed, practical shape. Thoroughly 
up to the times in every respect, containing many new 
prescriptions and formulae, and over two hundred and 
fifty illustrations, many of which have been drawn and 
engraved specially for this series. The authors have had 
large experience as quiz-masters and attaches of colleges, 
with exceptional opportunities for noting the most recent 
advances and methods. 

Cloth, each $1.00. Interleaved for Notes, $1.25. 
No. 1. HUMAN ANATOMY, " Based upon Gray." Fifth 
Enlarged Edition, including Visceral Anatomy, formerly 
published separately. 16 Lithograph Plates, New 
Tables, and 117 other Illustrations. By Samuel O. L. 
Potter, m.a., m.d., m.r.c.p. (Lond.), late A. A. Surgeon U. S. 
Army, Professor of Practice, Cooper Medical College, San Fran- 
cisco. 
Nos. 2 and 3. PRACTICE OF MEDICINE. Fourth Edi- 
tion. By Daniel E. Hughes, m.d., Demonstrator of Clinical 
Medicine in Jefferson Medical College, Philadelphia. In two parts. 
Part I. — Continued, Eruptive, and Periodical Fevers, Diseases 
of the Stomach, Intestines, Peritoneum, Biliary Passages, Liver, 
Kidneys, etc. (including Tests for Urine), General Diseases, etc. 

Part II. — Diseases of the Respiratory System (including Phy- 
sical Diagnosis), Circulatory System, and Nervous System; Dis- 
eases of the Blood, etc. 

*** These little books can be regarded as a full set of notes upon 
the Practice of Medicine, containing the Synonyms, Definitions, 
Causes, Symptoms, Prognosis, Diagnosis, Treatment, etc., of each 
disease, and including a number of prescriptions hitherto unpub- 
lished. 

No. 4. PHYSIOLOGY, including Embryology. Sixth 
Edition. By Albert P. Brubaker, m.d., Prof, of Physiology, 
Penn'a College of Dental Surgery ; Demonstrator of Physiology 
in Jefferson Medical College, Philadelphia. Revised, Enlarged, 
with new Illustrations. 
No. 5. OBSTETRICS. Illustrated. Fourth Edition. By 
Henry G. Landis, m.d.. Prof, of Obstetrics and Diseases of 
Women in Starling Medical College, Columbus, O. Revised 
Edition. New Illustrations. 



BLAKISTON'S ? QUIZ-COMPENDS ? 

No. 6. MATERIA MEDICA, THERAPEUTICS, AND 
PRESCRIPTION WRITING. Fifth Revised Edition. 
With especial Reference to the Physiological Action of Drugs, 
and a complete article on Prescription Writing. Based on the 
Last Revision of the U. S. Pharmacopoeia, and including many 
unomcinal remedies. By Samuel O. L. Potter, m.a., m.d., 
m.r.c.p. (Lond.).late A. A. Surg. U. S. Army; Prof, of Practice, 
Cooper Medical College, San Francisco. Improved and Enlarged, 
with Index. 

No. 7. GYNECOLOGY. A Compend of Diseases of Women. 
By Henry Morris, m.d., Demonstrator of Obstetrics, Jefferson 
Medical College, Philadelphia. 45 Illustrations. 

No. 8. DISEASES OF THE EYE AND REFRACTION, 
including Treatment and Surgery. By L. Webster Fox, m.d., 
Chief Clinical Assistant Ophthalmological Dept., Jefferson Med- 
ical College, etc., and Geo. M. Gould, m.d. 71 Illustrations, 39 
Formulae. Second Enlarged and Improved Edition. Index. 

No. 9. SURGERY, Minor Surgery and Bandaging. Illus- 
trated. Fourth Edition. Including Fractures, Wounds, 
Dislocations, Sprains, Amputations, and other operations; Inflam- 
mation, Suppuration, Ulcers, Syphilis, Tumors, Shock, etc. 
Diseases of the Spine, Ear, Bladder, Testicles, Anus, and 
other Surgical Diseases. By Orville Horwitz, a.m., m.d., 
Demonstrator of Surgery, Jefferson Medical College. Revised 
and Enlarged. 84 Formulae and 136 Illustrations. 

No. 10. CHEMISTRY. Inorganic and Organic. For Medical 
and Dental Students. Including Urinary Analysis and Medical 
Chemistry. By Henry Leffmann, m.d., Prof, of Chemistry in 
Penn'a College of Dental Surgery, Phila. Third Edition, Revised 
and Rewritten, with Index. 

No. 11. PHARMACY. Based upon " Remington's Text-book 
of Pharmacy." By F. E. Stewart, m.d., ph.g., Quiz-Master 
at Philadelphia College of Pharmacy. Third Edition, Revised. 

No. 12. VETERINARY ANATOMY AND PHYSIOL- 
OGY. 29 Illustrations. By Wm. R. Ballou, m.d., Prof, of 
Equine Anatomy at N Y. College of Veterinary Surgeons. 

No. 13. DENTAL PATHOLOGY AND DENTAL MEDI- 
CINE. Containing all the most noteworthy points of interest 
to the Dental student. By Geo. W. Warren, d.d.s., Clinical 
Chief, Penn'a College of Dental Surgery, Philadelphia. Illus. 

No. 14. DISEASES OF CHILDREN. By Dr. Marcus P. 
Hatfield, Prof, of Diseases of Children, Chicago Medical 
College. Colored Plate. 

Bound in Cloth, $1. Interleaved, for the Addition of Notes, $1.25. 

J8@* These books are constantly revised to keep up with 
the Latest teachings and discoveries, so that they contain 
all the new methods and principles. A r o series of books 
are so complete in detail, concise in language, or so well 
printed and bound. Each one forms a complete set of 
notes upon the subject under consideration. 

Illustrated Descriptive Circular Free. 



GOULD'S NEW 

Medical Dictionary. 

Based on Recent Medical Literature. 




Small 8vo, Half Morocco, as above, with Thumb Index, . . $4.25; 
Plain Dark Leather, without Thumb Index, 3.25 



A compact, concise Vocabulary, including all 
the Words and Phrases used in medicine, with 
their proper Pronunciation and Definitions. 



" One pleasing feature of the book is that the reader can almost 
invariably find the definition under the word he looks for, without 
being referred from one place to another, as is too commonly the 
case in medical dictionaries. The tables of the bacilli, micrococci, 
leucomai'nes and ptomaines are excellent, and contain a large 
amount of information in a limited space. The anatomical tables 
are also concise and clear. . . . We should unhesitatingly 
recommend this dictionary to our readers, feeling sure that it wilt 
prove of much value to them." — American Journal of Medical 
Science. 

JUST PUBLISHED. 
GOULD'S POCKET DICTIONARY. 12,000 
Medical Words Pronounced and Defined. 

Cloth, $'1. 00; Leather, $1.25 



